Archived: The Leys

Updated 23 February 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was carried out by two inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service. The Expert by Experience made calls to relatives.

Service and service type

The Leys is a ‘care home’. People in care homes receive accommodation and personal care as a single package under one contractual agreement dependent on their registration with us. The Leys is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was not a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with three people who used the service and nine relatives about their experience of the care provided. We spoke with seven members of staff including the provider, manager, and care workers.

We reviewed a range of records. This included seven people’s care records and multiple medication records. We looked at four staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We spoke to two professionals who work with the service.

Updated 23 February 2023

About the service

The Leys is a residential care home that can provide care and support for older people and people living with dementia. The service is registered to provide accommodation and personal care to a maximum of 33 people. At the time of inspection 12 people were using the service.

People’s experience of using this service and what we found

Risks to people had not always been mitigated. We found risks associated with water temperature, food temperatures, environment and equipment.

Risks associated with people’s health conditions were not always thoroughly assessed and mitigated. People with risks from known health conditions did not always have details recorded and factors to reduce the risks were not always identified or followed.

Effective systems were not in place to protect people from the risk of potential abuse. Safeguarding procedures had not always been followed. Records of injuries were not detailed and follow up checks were not recorded.

Records of injuries and accidents were not always reviewed by the manager, to identify concerns and improve practice when needed.

Records did not evidence that staff supported people with all of their individual needs, such as continence tasks or personal hygiene tasks.

Medicine management required improvement. Records were not always clear regarding which medicines were currently prescribed. Reasons for administering as required medicines were not completed.

Systems and processes to provide oversight of the service were ineffective in identifying improvements needed. Concerns found on this inspection had not been previously identified or mitigated by the provider.

The provider had not always followed the requirements under the duty of candour. The duty of candour requires registered providers and registered managers to act in an open and transparent way with people receiving care or treatment from them. The regulation also defines ‘notifiable safety incidents’ and specifies how registered persons must apply the duty of candour if these incidents occur.

People and relatives told us they were supported by staff who knew them well and had been trained to meet their needs. People and relatives were positive about staff.

People were supported to have maximum choice and control of their lives but staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not always support this practice.

People, relatives and staff all knew how to complain and felt their concerns would be dealt with appropriately. Feedback was requested from stakeholders.

The service had received a five-star food hygiene rating on 12 April 2022 from the food stand agency.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was Inadequate (published 1 February 2022) and there were two breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found improvements had not been made and the provider was still in breach of regulations.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection. We undertook a focused inspection to review the key questions of safe and well-led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has not changed from inadequate based on the findings of this inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to risk mitigation, records, medicines and oversight at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Special Measures:

The overall rating for this service is ‘Inadequate’ and the service remains in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.