St Leonards Rest Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

During our assessment we assessed all quality statements in the safe key question. We found safety concerns, which have resulted in 4 breaches of regulation relating to consent, safeguarding, safe care and treatment and staffing. The scores for these areas have been combined with scores based on the rating from the last inspection, which was requires improvement. Not all risks for people were identified and recorded in relation to their care and support needs to ensure their safety and wellbeing. This meant people were placed at risk, as there was a lack of action to mitigate these risks. The provider had not taken sufficient action to keep people safe and refer to the external safeguarding team after people had been in altercations in the home. Safety risks to people were not managed well. People did not always live safely and free from unwarranted restrictions. The service had not always assessed, monitored or managed safety well.

This service scored 38 (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 Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People told us they felt safe in the environment. “I feel safe. Staff can’t do enough”, “I am fine here yes, and “I am well looked after here. Staff are very helpful. Most of the staff are nice but are busy they do not have much time to chat”. A person said a member of staff verbally ‘lashes out’ but the rest of the staff are kind.

Staff told us they received safeguarding training and knew how to identify safeguarding concerns and report them to the provider. However, there was a lack of evidence that staff had received training in safeguarding. Staff told us several incidents had occurred, however there were no records of these events. For example, staff had found 1 person self-harming on 2 occasions. Staff said the provider made the safeguarding referrals, however, we found safeguarding referrals had not been made by the provider when required. No incidents had not been referred to the local authority safeguarding team by the provider. This means these allegations of abuse had not been investigated by an external stakeholder. We raised these with the local authority.

We observed a listening monitor in the small dining area, and when we were in that room, we could hear everything that took place in the person’s room. Staff said the monitor helped them in managing their needs. However, the monitor meant the person’s privacy and dignity were compromised. We saw the door to a short corridor that passed the kitchen into the laundry was often open meaning people were placed at risk as they could access these areas.

The provider had completed an initial assessment for a person and identified they were known to self-harm. The provider failed to mitigate these risks as records showed no risk management plans in relation to self-harm were put in place when they were admitted to the home and following other witnessed incidents of self-harm. The provider told us of other items this person’s bedroom which may continue to pose a risk of self-harm had not been risk assessed and risk management plans were not in place to reduce the risk of harm. These incidents had not been reported to the local authority’s safeguarding team. We requested assurances from the provider on 2 August 2024 of how they planned to keep this person safe. This evidence was not provided to us placing the person at significant risk. On 1 occasion staff had called the police due to the behaviours of 1 person and their impact on other people and staff. The local authority were unaware of these concerns, this meant that people were at risk as this risk to their safety was not investigated. We asked the provider to send us a copy of the safeguarding referrals they had made for these incidents. We did not receive them. We found that 1 person had been restricted from leaving the home as they were at risk of abuse from others. However, there was no assessment or Deprivation of Liberty Safeguards (DoLS) application in place. The provider said these had been applied for but did not send us a copy of this application when asked. DoLS are important human rights safeguards; they aim to ensure that such deprivation of liberty only happens when it is necessary, proportionate and in the person’s best interests. Since our last visit to the home, the provider sent us a copy of mental capacity assessment for 1 person, this related to their lack of ability to decide where they could safely live and their support needs. The provider told us that an emergency DoLS and a standard DoLS request was in place.

People who were independent were able to access the community. There were people who smoked, and they told us they knew where the safe smoking areas were. On 2 August 2024 1 person told us they were unable to use their bus as they had lost it and the provider was in the process of getting them a new one.

Staff did not always possess the information and knowledge to work with people’s individual needs to be able to keep them keep them safe. Staff told us they were restricting a person’s from accessing the community following safeguarding allegations. Staff also told us a person had left the building without support. There were no records of these allegations or incidents and one of these people had previously been under a DoLS. Staff were able to tell us who had capacity to make decisions about their safety. However, people’s care records did not reflect the information staff gave us and were often missing. This meant that any new staff at the home would not know who had capacity or who were under safety restrictions. The provider could not be assured staff could access accurate information regarding people’s risks. The provider told us they hold bank cards and pin numbers, for 3 people. None of these people’s care records had been completed for money management. The provider told us they had permission from Hampshire adult services. We asked for this agreement to be sent to us along with records of how they managed these monies. Although the provider sent us a letter explaining how they managed the money for 3 people we did not receive records of how these monies were managed or the written agreement from the local authority. On the 2 August 2024 we asked the provider about the bus pass and they told us they had it. They said they would give it to staff if the person needed to use the bus. Records did not show the person had consented to this arrangement or lacked the mental capacity to make this decision or that a best interest decision had been made to restrict their access to their bus pass. This meant there was a lack of assessment of restrictive practices to determine whether lawful decisions had been made in relation to the risk of harm, placing service users at risk of inappropriate restrictions.

Staff were observed supporting people in communal parts of the service. People were observed being supported with meals and drinks. Staff spoke about people’s eating and drinking risks and how they ensured people had sufficient drinks especially in hot weather. We observed staff gave out cold drinks and ice creams on a hot day during our inspection.

When we reviewed the care records the dashboard for the care records stated 3 people had a DoLS in place. There was no information in relation to Lasting Power of Attorney (LPA) or DoLS in the records although the provider said there were some people who’s next of kin held an LPA. They had not seen these documents and had not checked with the LPA system. This meant there was a risk of financial abuse. Due to the concerns regarding 1 person’s health and behaviour, staff told us they were restricting them from leaving the home. There was no assessment of their capacity and their support plan for going out said they went out on their own. The provider told us the person’s next of kin had LPA, however there was no assessment regarding capacity for managing monies and being safe outside the home. Not all risks for people were identified or recorded in relation to their care and support needs to ensure their safety and wellbeing. For example, 1 person’s falls risk assessment identified them as being at minimal risk of falls. However, they were prescribed which increased their risk of falling. They were also prescribed a blood thinning medicine, which increases the risk of excessive bleeding. This person’s falls care plan did not include information of action staff should take. This increased their risk of harm in the event of a fall. Systems were not always in place to ensure people's assessed needs were planned for. This meant people were placed at risk, as risks to their wellbeing had not been recorded effectively and there was a lack of action to mitigate these risks. There were no systems in place to identify themes and trends. There was no evidence that clinical governance audits were completed to enable oversight of themes and/or trends identified within the service, for example risks, accidents and incidents and people’s weight loss.

People told us they felt the home was safe. However, we did find that not enough had been done to mitigate the risk of harm to people in the environment. We raised this with the provider who told us of plans they were going to take to keep people safe. However, we did not receive any action plans or confirmation of when work would take place.

Staff told us they felt the home was safe and appropriate for the people who lived there. The provider told us the property was old and the internal doors expand and shrink. This impacts on the door measurements, however, the provider told us they had sourced a supplier to adjust the doors, so they would be compliant with current fire door regulations. This work had not been booked.

On the first floor, we saw an empty bedroom that was being used to store many mobility aids such as frames and wheelchairs. The door didn’t have a handle and there were two holes in it. This door had been highlighted as a concern in a fire risk assessment in November 2023, but action had not yet been taken to fix it. Another room smelt damp and staff told us this was not being used and showed us the dehumidifier. The provider said the reason for the dampness had not been addressed. Staff told us 1 room had not been used for some time, the carpet was loose and an area by the wall was missing, leaving exposed wooden floorboards. This meant that if these rooms were needed for any reason, they were not safe. The sun lounge had gaps between the wall and ceiling and the ceiling appeared to bow. The provider told us they planned to renovate this area. The provider has told us they have accepted a quote to repair the roof, but did not provide evidence of timescales for this when requested.

We found multiple recommended actions from a fire risk assessment in November 2023 had not been completed. We asked for an action plan and date for these actions. We did not receive this. We noted many old items in the garden, some of which were blocking an alternative fire exit. The provider told us there were plans to remove the items. On our last visit in August this had not been completed. We asked for a date for the removal of the items and repairs to various areas in the home. We did not receive this.

People told us staff were busy but could be approached if they needed something.

Staff told us they felt there were usually enough staff to support people’s needs. The provider told us the home was fully staffed and there was no agency use at the service. The provider explained that some people had capacity to make decisions about leaving the home and how they wanted to spend their time and the staffing levels were suitable to meet the needs of those needing support. The provider told us staff had monthly supervisions. We asked for 2 samples of staff supervision but did not receive them. The provider told us staff discussed issues such as medicine changes in handover meetings. However, the handover notebooks we looked at had reminders for staff on showers and medicine changes. The provider told us staff meetings took place twice a year. Topics discussed included fire safety, staffing, annual leave, feedback and information sharing, kitchen and nighttime cleaning. The provider sent us two examples of records for these meetings at the factual accuracy stage of the assessment.

The provider told us that the cook prepared food for tea in the afternoon where possible, otherwise the 2 care staff could support with tea and supper. It was possible that if people needed support 2 staff may not be sufficient in the event of any incidents or individuals needing support in their daily living. We observed people could not go out when they wanted unless they were independent. Staff told us for those needing support to this needed to be planned. This means people were restricted in the times of day they could access the community. There were areas of the home which had odours, although there was a cleaner employed. However, after they went off duty any other infection control incidents would have been dealt with by care staff. With 2 staff on duty in the afternoon, at night and weekends, it is possible that there would be risk in the management of infection control and cleaning.

The provider was unable to provide evidence that staff had up to date training, relevant to their role. When we requested a list of all staff and their training, the provider sent a total of 6 certificates for only 3 members of staff. Although the certificates were in date, we could not be assured all staff received sufficient training.. There was no evidence staff were provided with appropriate training and guidance. The failure to ensure risk assessments were monitored increased the risks of people not receiving appropriate support in a consistent and safe way. One person’s personal evacuation escape plan (PEEP) assessed them as low risk in the event of an evacuation. However, it also stated they needed someone with them all the time, and they needed to remain in sight. However, we were not assured this could happen during afternoons and at night when there were only 2 staff on shift. It was noted that there were only 2 members of care staff on duty at weekends both morning and afternoon and at night. Therefore, it could not be determined if the home was staffed safely to meet people’s needs and to keep them safe in the event of a fire.

People we spoke with told us the home was clean and raised no concerns.

The provider told us the home had cleaning schedules. On our first day we observed 3 rooms had an unpleasant odour. The provider told us 1 room was damp and we had been to the rooms before the cleaner had been to them. The provider did not send us the cleaning schedules when requested. Therefore, we could not be assured that provision was in place for ongoing infection control. One bedroom had strong odour. Staff told us it was odour caused through ill health of previous occupant. The carpets had been cleaned several times, but the odour remained. We raised our concerns about the rooms and the provider told us we had been to the rooms before the cleaner had been in them. However, the rotas showed the cleaner finished at 2pm and we viewed the rooms after this time.

We saw a lot of rust on the oven door. Two of the kitchen units had missing front covers, exposing bare wood. This increased the risk of bacteria remaining, even after thorough cleaning. We contacted environmental health to advise them of our concerns. On the 15 July we observed offensive waste being stored in a domestic waste bin in the laundry room. People could have access to this area. The unsafe disposal of used continence pads placed people at risk of infection. We saw a cat was asleep on a dining room table on the morning of our first day. We did not see the table being cleaned and it appeared to have the same tablecloth on it when 2 people sat there to eat their lunch. On both days we saw food uncovered, not labelled or dated and left on the side. On the first day we discussed this with the shift leader and showed them the concerns. On the second visit we showed the provider who then reminded staff what they should do. This means the food was open to be being contaminated, for example by flies.

We reviewed the provider’s infection control policy, The policy does not state the date it was written, however it was last reviewed this policy January 2024. Page 3 of the policy stated, “The home does produce Offensive Waste-soiled pads and other incontinence products. These are put into the yellow bags provided, filled only to two thirds capacity and taken to the yellow bin at the side of the home for collection, normally every other Monday morning by a contractor”. The provider told us it was their expectation that staff would, double bag the offensive waste into domestic bin bags, after providing personal care to a service user. Staff would then place the bag in the bin in the laundry room. Once the bin was full, staff then transferred the offensive waste into the yellow bags provided then into the yellow bin outside the building. Domestic bin bags are not designed to hold offensive waste and placed staff at risk of the bags splitting and dropping waste on them whilst transferring them to yellow bags. The provider told us they are replacing all old and worn carpets but did not give a time scale on when this would be completed. The provider told us the process to clean urine off flooring and furniture was to place paper towels over area, then bleach in circles and more towels. We discussed the issue of chemical reaction between bleach and urine. This can produce chlorine gas placing staff and people at risk. The provider told us they would not change this process.

We could not collect sufficient evidence to score this evidence category.

Staff explained how they knew the individual needs of the people they supported, and 1 resident was self-administering 1 of their medicines. Although a risk assessment has now been sent this did not include an ongoing monitoring process for the self-administration. Staff described how when new supplies of medicines and medicines administration records (MAR) were received each month they reviewed the quantities of medicines held and the previous months MAR for gaps. However, this was not recorded or formally reviewed within an audit cycle. Therefore, we were not assured the service was assessing, monitoring or improving medicines optimisation within the service.

Medicines were stored securely including controlled drugs (CDs). The administration of medicines including creams administered as part of personal care were recorded within the medicines administration record (MAR). People’s MAR's included their photograph, details or allergies and intolerances and how they preferred to take their medicines. Temperature monitoring and controlled drugs records were generally complete. These could be improved through the addition of maximum and minimum temperatures and more detail when CDs were returned to their preferred community pharmacy. Homely remedies were available at the service to treat minor conditions the residents may have. However, the policy available to staff was dated 2012. Whilst information to support the administration of eye drops, variable dose, when required medicines and homely remedies were available to staff, they lacked sufficient personalised information. Therefore, we were not assured that accurate, complete medicines records were consistently maintained.