Leabrook Lodge Limited was rated Requires Improvement following a focused inspection in April 2023, with breaches of Regulation 12 (Safe Care and Treatment) and Regulation 17 (Good Governance) identified due to unsafe medicines management, absent risk assessments, and ineffective quality monitoring systems. The service had no registered manager in post, lacked formal staff supervision and quality assurance processes, though staff recruitment, infection control, and safeguarding training were found to be satisfactory.
Concerns (10)
criticalMedication management: “The provider did not complete risk assessments associated with people's medicines. The provider did not have assessment in place for the safe storage of medicines including any medicines which were temperature sensitive.”
criticalMedication management: “The provider did not have guidelines in place for staff to safely support people with 'when required' medicines including the maximum dosage within a 24-hour period to keep people safe.”
criticalCare planning: “Staff members were not given current or accurate information on how to safely support people in their own homes as risk assessments had not been completed.”
criticalGovernance: “The provider did not have effective quality monitoring systems. There was a lack of checks to ensure people received good care.”
moderateStaff competency: “Although staff had received training in the safe use of medicines, they did not receive any spot checks or assessments of competency to ensure they followed safe processes.”
moderateIncident learning: “The provider did not effectively review all incidents, accidents or near misses to see what could be done differently to minimise the risk of reoccurrence.”
moderateLeadership: “The provider did not have a manager registered with the CQC at the time of the inspection.”
moderateSupervision / appraisal: “There was a lack of formal one-to-one with staff members or staff meetings. Staff believed they received information on an "ad-hoc" basis with no formal process.”
moderateSafeguarding: “The provider did not make information available to people, staff or relatives on how to report any concerns.”
minorPerson-centred care: “The provider had yet to formally introduce systems where they could gather and act on people's experiences of care and make improvements based on the responses.”
Strengths
· Staff arrived when expected and stayed for the agreed length of time.
· The provider followed safe recruitment checks including DBS checks.
· Staff had received training to recognise and respond to safeguarding concerns.
· The service was working within the principles of the Mental Capacity Act 2005.
· Staff had received infection prevention and control training and had access to appropriate PPE.
Quality-Statement breakdown (9)
safe: Using medicines safelyRequires improvement
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Learning lessons when things go wrongRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseRequires improvement
safe: Staffing and recruitmentGood
safe: Preventing and controlling infectionGood
well-led: Managers and staff being clear about their roles and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringRequires improvement
well-led: Continuous learning and improving careRequires improvement