Archived: Leven House

Updated 30 May 2018

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This was a comprehensive inspection which took place on 20 March 2018. The visit was unannounced which meant the service did not know that we were visiting. Two inspectors carried out this inspection

We reviewed information we held about the service, including the notifications we had received from the provider. Notifications are changes, events or incidents the provider is legally obliged to send us within required timescales. We also contacted the local authority commissioners for the service and the clinical commissioning group (CCG); their feedback informed this inspection report.

We spoke with four people and two relatives. We also spoke with the acting manager, two senior carers, the cook and two care assistants. We looked at the care records for four people who used the service, people’s medicines records and recruitment records for four staff. We also looked at a range of records related to the quality and safety of the home.

Updated 30 May 2018

This inspection took place on 20 March 2018 and was unannounced. This meant the provider and staff did not know we were coming. The visit was undertaken by two adult social care inspectors.

Leven House was last inspected in January 2017 and was found to be compliant with the required regulations and rated as Good.

Leven House is a ‘care home’. People in care homes receive accommodation and personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Care is primarily provided to older people requiring residential or respite care and the service can accommodate up to ten people. There were ten people living at the home at time of the inspection.

A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. At the time of our inspection there was an acting manager in post who had applied to be registered with CQC.

We found arrangements were not in place to ensure people were given their medicines in a safe manner.

Accidents and incidents were not always well recorded and were not reviewed for trend analysis.

Risks assessments for people were not robust or reflective of their current risks and needs.

We found an unlocked door which housed a storage area containing items such as liquid paint stripper and a carpet in a corridor that was taped down as it had lifted. These could mean potential hazards. The manager addressed the cupboard immediately and told us they would address the flooring trip risk.

There was a recruitment procedure in place, reducing the risk of an unsuitable person being employed to work with vulnerable people.

Staff who were new to the service told us they underwent an induction period, however this was not well recorded.

We found training records were in place which demonstrated staff had received appropriate training. Staff told us they had received training in moving and handling, administering medicines and first aid.

Records relating to the Deprivation of Liberty Safeguards were not well maintained meaning it was difficult to track if people had current authorisations in place .

The service had considered people’s food and fluid intake and put in place specific plans to meet individual people’s needs. Relatives were confident people were receiving the required nutrition.

We found staff were now receiving appropriate support through supervision and appraisal and the manager had a plan going forward to address supervisions.

People and their relatives and told us the service was caring.

The service supported people to engage in the local community to prevent social isolation and to have pets where they chose to.

Assessment records were not always well completed. Care plans were in place however these were not always up to date or contained information required to support a person safely.

Quality audits had not been in place since July 2017. This meant the provider was not assessing and monitoring the service to improve the quality.

Policies and procedures that we viewed were out of date with many showing no review undertaken since 2010.

People’s views had not been sought since 2016 although people we spoke with knew how to raise a concern and told us they felt listened to by the staff and manager at the home.

During our inspection we found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.