Background to this inspection
Updated
14 January 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
The inspection was completed by 2 inspectors.
Service and service type
Leahyrst Care Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. West Ridings is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
The service had a manager registered with the Care Quality Commission. 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.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
Before the inspection we reviewed the information we held about the service and the service provider. 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 looked at the notifications we had received for this service. Notifications are information about important events the service is required to send us by law. We used all of this information to plan our inspection.
During the inspection
We spoke with 6 people to gather their views about the care they received. We looked at 5 people's care records. We checked recruitment, training and supervision records for staff and looked at a range of records about how the service was managed. We also spoke with the registered manager, 6 care and ancillary staff.
Updated
14 January 2023
About the service
Leahyrst Care Home is a residential care home providing accommodation and personal care to up to 41 people. The service provides support to older people and people with sensory impairments. At the time of our inspection there were 36 people using the service.
People's experience of using this service and what we found
Quality assurance processes were not always effective in identifying concerns and areas for improvement. People's care plans were not always reflective of people's current care needs and risks and care plan audits had not identified areas that required improvement. Environmental risks and some checks had not been regularly documented.
Medicines were safely stored. People received support with their medicines from staff members who had been trained and assessed as competent.
People were supported by enough staff who were available to assist them in a timely way. People were protected from the risks of ill-treatment and abuse as staff had been trained to recognise potential signs of abuse and understood what to do if they suspected harm or abuse.
The provider had assessed the risks associated with people's personal care and support. Staff members were knowledgeable about these risks and knew what to do to minimise the potential for harm. However, some records contained conflicting information.
People were supported to have maximum choice and control of their lives and the provider supported them in the least restrictive way possible and in their best interests; the application of the policies and systems supported good practice.
People were referred to additional healthcare services if needed and staff were knowledgeable about any recommendations or treatments.
People were supported by staff members who were aware of their individual protected characteristics like age, religion, gender and disability.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was requires improvement (published 5 February 2021). The service remains rated requires improvement.
Why we inspected
This inspection was prompted by a review of the information we held about this service. As a result, 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 remained requires improvement 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 a continued breach in relation to good governance at this inspection.
Please see the action we have told the provider to take at the end of this report.
Follow up
We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.