Archived: Legh House

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

Safeguarding systems, processes and practices were mostly effective to help ensure people were protected from the risk of abuse. However, staff had not always completed up to date training to ensure they followed best practice guidance. Robust detailed handovers ensured staff knew how to reduce the likelihood of harm to people living at the home however, risk assessments had not been regularly reviewed. The registered manager was able to locate documents to demonstrate staff had been recruited safely into the home however, these were initially not in place when we reviewed recruitment files. Staff told us they felt supported however, had not always received regular supervision. Staff had not always received training that was relevant to their roles and responsibilities, and this had placed people at risk of harm. This was a breach of the legal regulations.

This service scored 75 (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.

We spoke with 6 people they all told us they felt safe. One person said, "I feel perfectly safe, I have no reason to feel otherwise." Everyone told us they would speak with staff if they had concerns and told us staff were kind and approachable. We spoke with relatives who told us their loved ones were safe. One relative told us, “I do feel [loved one] is safe, there always seems to be someone around. [Loved one] can pull the cord and they get to them pretty quick if they need help.”

Whilst staff understood how they ensured consent from people day to day, Mental Capacity Assessments for people who lacked capacity had not always been completed appropriately. We discussed this with the registered manager, and they took immediate action to rectify this. By the end of our assessment, they had completed training and sought professionals advice. We were provided with evidence to demonstrate learning had taken place and Mental Capacity Assessments were now being completed appropriately. A safeguarding policy was in place this included the names and address of the local safeguarding team. The provider had a safeguarding audit in place however, the actions identified did not provide enough detail. For example, recording was responsible for meeting the action and by when. This meant actions were at risk of not being completed.

All staff understood their responsibilities to report any concerns and were able to describe the signs that might indicate someone was at risk. Whilst staff were not always sure which other organisations they should report to, they knew where this information was held. Staff told us they asked people their consent before commencing any care. The registered manager described the system in place for reporting and monitoring any safeguarding concerns. There had not been any safeguarding incidents in the year prior to our visit. They were able to give an example of how concerns were addressed, and learning shared in response to feedback.

There was a robust detailed handover in place to ensure staff were aware of people’s changing care needs and what actions they needed to take to keep people safe from harm however, risk assessments had not been regularly reviewed and kept up to date. The registered manager told us they were aware and had plans in place to improve. Care plans and risk assessments were being reviewed by senior staff as the home transferred onto an electronic care planning system. Quality and monitoring audits were in place to identify risk. We reviewed a monthly audit of accidents and incidents; however, the form did not give an indication of who the concerns were escalated to and how the information was used. This meant actions were at risk of not being identified and completed.

We observed people had access to the equipment they needed to maintain their mobility and skin integrity. People had access to call bells and fresh drinks throughout our visit. We saw staff walking with people to provide support and reduce the likelihood of falls. During our visit 1 person fell, we observed that staff supported the person calmly and compassionately, they understood the additional risks the person faced due to their medicines and acted accordingly.

Staff understood the risks people faced and the actions that were needed to reduce these risks, they were able to describe the measures consistently and described how they shared this information with colleagues. The registered manager described how they understood people's views about risks and how they wished to be supported at assessment. They described how risks were reviewed and staff kept up to date with any changes through a robust hand over system. The registered manager was planning to join care home forums to ensure they stayed up to date. They also explained how the provider shared learning from their other service locations to support with ongoing risk management.

People told us they were involved in their own risk management, referring to decisions they made day to day. One person was very clear "I am in charge of my own risk." Relatives told us they felt included in the planning of care and the actions put into place to reduce the likelihood of harm from identified risks. One relative told us, “[loved one] does have a care plan and I was very involved.”

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

Staff had not always received up to date training and some of these courses were mandatory as essential to ensure staff can complete fulfil their roles safely. We found 10 staff had not completed Health and safety training, 14 staff had not completed Infection control training, 18 staff had not completed safeguarding training, 19 staff had not completed moving and handling training and 0 staff had completed learning disability training which is a legal requirement to do so since July 2022 We discussed this with the registered manager who told us they were aware staff training had fallen behind and had plans in place to improve. We reviewed 3 staff member members recruitment files and identified missing information which meant we could not be assured people had been recruited safely into the service. For example, 2 staff members had gaps in their employment which had not been explored. We discussed this with the registered manager who located the missing information and told us they would implement a checklist to ensure recruitment files would reflect robust recruitment processes. Staff had not always received regular supervisions and appraisals. The registered manager told us they were aware and had implemented a tracker system to improve.

Staff told us they felt there were enough staff. Staff said they had enough time to speak with people and when they had once fed back to the registered manager about feeling low in staffing levels, this had led to an additional staff member on shift. Staff felt supported to do their roles. Staff described the training they had access to and said they could ask for any other training they felt they needed in order to carry out their job role effectively. One new staff member described their induction and told us this was effective. The registered manager described how staffing levels were changed to reflect people's needs. They described the processes in place to ensure staff felt supported and that disciplinaries could be conducted fairly. The registered manager and deputy work to ensure staff feel supported. They expressed that care is a demanding job and staff should feel they have help if they need it. The deputy described the support available to her as "phenomenal."

We observed there were sufficient staff to meet people's needs including the ability to spend time chatting with people.

People told us staff were available when they needed them and knew how to support them. One person said, "If I want anything I press the bell." and another said, "I have a bell, if I press it the staff come." We spoke with 3 relatives who told us there were enough staff. One relative said, “I guess there are enough carers, it's very noticeable when they are short of staff due to sickness but the remaining carers work harder and I am happy [loved one] is not overlooked.” and another relative said, “There always seems to be someone around."

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.