St Leonards Rest Home

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We identified 2 breaches of regulation in relation to the governance and managerial oversight of the service. The provider failed to have clear and effective governance, management and accountability arrangements. At previous inspections breaches of regulations and areas for improvement were identified. At this assessment, we identified you had failed to embed and maintain the improvements made at the last inspection in relation to safe care and treatment, staffing, good governance, in addition to further breaches relating to safeguarding, need for consent, notice of changes to the running of the service and notifications of other incidents.   Following our visit on the 15th of July we raised safeguarding concerns about concerns and shortfalls found during our visits to the home.

This service scored 46 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff told us when incidents occurred, they documented them and left them for the manager or provider to review. Staff told us they felt the service was well led and felt confident the provider would listen to them. However, we found that incidents or allegations reported to both the police and the provider had not been referred to safeguarding and had not been reviewed or investigated by the provider to ensure appropriate action had been taken. This placed people at risk of repeated unsafe events. When incidents occurred, people’s care plans had not always been reviewed and updated to inform staff of any new concerns, potential triggers, or de-escalation techniques. This meant there no processes to ensure that lessons were learnt, and improvements made. The provider told us staff meetings took place twice a year. The provider confirmed they could log into the system used to send records during our first visit, but following our visits they told us they could not use it. However, they emailed inspectors directly and successfully sent us some requested documents.

The provider failed to have clear and effective governance, management and accountability arrangements. The management team had not consistently updated people’s care plans for example the scoring. The provider failed to have systems in place to manage current and future performance, or systems to manage risks to the quality of the service. There were no systems, processes or audits to identify the issues found during the assessment including the management of safeguarding. The provider failed to send us notifications of serious incidents, deaths and allegations of abuse, they also failed to inform the local authority safeguarding team of allegations of abuse. A staff member told us a person had recently died but we did not receive a notification of the death as required. The provider failed to notify us of incidents or inform adult services safeguarding team. This increased the risk to the health, safety and wellbeing of people. It showed indications of a closed culture within the service, increasing the risk of abuse, neglect and breaches to the human rights of people. There was no managerial oversight of the training of staff and testing of their competencies. The provider did not have a system to review people’s experiences to ensure they were receiving care that met their needs. The provider had failed to ensure staff managed people’s food and eating environment safely placing them at risk of exposure to harmful bacteria and ill health. There was no record of how a clean environment had been maintained. We were not assured regular and effective cleaning took place to prevent the presence of bacteria in the home. Staff told us that they audited medicines however there was no record of this taking place. The provider failed to provide us many documents we requested. For example, action plans and dates when work to improve the environment and fire safety would take place, safeguarding referrals and investigation reports.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.