St Leonards Court

Updated 21 December 2021

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 Care Act 2014.

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

Two inspectors carried out this inspection.

Service and service type

St Leonards Court is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a new manager who was applying to be registered with the Care Quality Commission.

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 and professionals who work with the service. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.

During the inspection-

We spoke with three people who used the service about their experience of the care provided. We spoke with four members of staff including the regional operations manager, manager, and care workers. We observed the care to help us understand the experience of people who could not talk with us.

We reviewed a range of records. This included two people’s care records and multiple medication records. We looked at three 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.

Updated 21 December 2021

About the service

St Leonards Court provides accommodation and personal care for up to 25 older people some of whom may be living with dementia. At the time of our visit there were 22 people using the service. The home is situated in the village of Mundford in Norfolk.

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

People were not always receiving safe care and treatment. Allegations of abuse or harm had not always been reported to the local safeguarding team or the Care Quality Commission (CQC). We could not be sure that these allegations had been dealt with appropriately or that action had been taken to prevent a reoccurrence. During the inspection we made safeguarding referrals to the local authority safeguarding team. There was not always effective oversight or management of incidents which had occurred. As a result, staff were placing themselves and others at risk. Incidents recurred and people were harmed. The manager took immediate action to ensure safeguarding procedures were followed to keep people safe.

Infection, prevention and control measures were not always being followed to prevent the spread of infections. Staff had received training and regular information updates throughout the pandemic. Infection control and cleaning audits were being undertaken to identify any issues quickly so that action could be taken to make any improvements.

Risk assessments had been completed to reduce risks to people’s health and safety when possible.

Staffing levels were sufficient to meet people’s needs in a timely manner. Vacant roles had recently been recruited to. Recruitment procedures were followed to ensure that staff suitable to work with vulnerable people were recruited.

Safe management of medicines procedures were being followed to ensure people received their medicines as prescribed. When errors in the administration of medication occurred, these had been identified and action taken to prevent a reoccurrence.

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 Good (report published August 2018).

Why we inspected

We received concerns in relation to staffing levels, the cleanliness of the home, and people not receiving adequate personal care. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from good to requires improvement. This is based on the findings at 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.

We have found evidence that the provider needs to make improvements. Please see the safe and well led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

Since the inspection the provider has taken steps to mitigate the risks. Processes have been put in place to ensure that all safeguarding concerns are reported to the local authority and the Care Quality Commission. The allocation of staff now ensure that there is a member of staff present in the communal areas during the daytime to support and monitor people.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for St Leonards Court on our website at www.cqc.org.uk.

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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to keeping people safe from harm. Please see the action we have told the provider to take at the end of this report.

We also identified that not all notifications had been sent to the Care Quality Commission as required. We are continuing to investigate this.

Follow up

We will request an action plan for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.