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Jonathan Charles Leonhardt
Registered role
Adult Care Home Manager
Removal by Agreement
Previously Sure Plan Homes Ltd
Type of hearing
No Panel held – Removal by Agreement process

Decision summary

Removal by Agreement means that through this process, a registered person can apply to be removed from the Register without being referred to a Panel.

The decision to agree to the application is made at a Case Conference. A registered person can apply for this at any stage in the fitness to practise process.

Applying for removal by agreement does not mean that a registered person has the right to be removed, but it enables Social Care Wales to agree to removal in an appropriate case.

The decision whether to agree the application is made taking into account whether the allegation involves exceptional public interest issues.


1. Mr Jonathan Charles Leonhardt ('Mr Leonhardt') registered with Social Care Wales (SCW) as an Adult Care Home Manager on 26 October 2011. He was employed by Sure Plan Homes Limited as the Registered Manager of Meadow House Nursing Home in Swansea. He commenced that role in February 2017. The home was closed on 30 August 2019 and all of the residents were moved to other homes. Mr Leonhardt was made redundant at that point.

2. Prior to the closure of the Home, the Home had been placed on escalating concerns for which an Action Plan had been developed. Swansea Council led on the Action Plan, which also involved Swansea Bay University Health Board (SBUHB), Neath Port Talbot County Borough Council (NPTCBC) and Care Inspectorate Wales (CIW).


Whilst registered as an Adult Care Home Manager and employed by Sure Plan Homes Limited as Manager.

(1) Between December 2018 and 3 February 2019, in relation to Individual A you did not ensure that:

(a) bowel movement records were kept;

(b) repeat prescriptions for laxatives were followed up

3. On 3 February 2019, Individual A died and a death certificate was issued indicating death was by natural causes. However, an inquest had taken place which concluded the death was due to faecal impaction. The CPN noticed this and raised it as a concern as the service user had been prescribed the anti-psychotic medication clozapine, a side effect of which is constipation. Laxatives were routinely prescribed and bowel movements were monitored and recorded. Individual A required incontinence pads so that their bowel movements would have been easily checked. Bowel movement was also reviewed at a regular clozapine clinic, which was held fortnightly. On inspection, it was discovered that the bowel movements record had not been kept. There had been a gap of four to six weeks when laxatives had not been given and the repeat prescription for laxatives had not been followed up. Ultimately, this was the responsibility of the Registered Manager, Mr Leonhardt.

4. At a Strategy Meeting on 6 June 2019 Mr Leonhardt admitted that he ultimately had responsibility for this.

(2) You failed to ensure that there were appropriate numbers of staff at all times.

5. Levels of staffing had been raised by CIW in inspection reports and by the Local Authority. From monitoring visits, it was found that the Home never had a full complement of staff team and often employed agency staff.

(3) You failed to ensure that all staff were fit to work at the Home as full and satisfactory information was not available for all members of staff.

6. Following an inspection of the Home by CIW, a Non-Compliance Notice was issued on 17 June 2019. This referred to the absence of full and satisfactory documentation in respect of all members of staff. In particular, it was noted that gaps in the employment histories of two members of staff had not been explored in order to obtain full employment histories. In addition, some files did not contain a recent photograph. The impact of individuals using the service was said to be that not all precautions had been taken to keep them safe.

(4) You failed to ensure that there were effective arrangements in place for monitoring, reviewing and improving the quality of care and support provided by the Home.

7. On 17 June 2019 another Non-Compliance Notice was issued in relation to a failure to ensure that there were effective arrangements in place for monitoring, reviewing and improving the quality of care and support provided by the Home. Quality Assurance Policy and Procedure was said to be insufficient and not fit for purpose. It was noted that there was no written plan for auditing activities to undertake checks on quality of care.

8. In addition, there were no effective arrangements in place to ensure all of its health and safety checks were up to date and satisfactory. The Non-Compliance Notice also stated that the systems and processes were not continually reviewed to enable identification of where quality and safety of services were being or may have been compromised.

9. The Non-Compliance Notice said that significant action was needed to ensure that such effective arrangements were in place. At the time of the inspection, it was acknowledged that progress against plans was not monitored against plans to improve quality and safety or that immediate action was taken when progress was not as expected.

(5) You failed to ensure that arrangements were in place to monitor Individual B.

10. Individual B was subject to Deprivation of Liberty legislation, but managed to routinely abscond. This was despite the Local Authority funding 1:1 staffing and extra security on the exit doors being in place. The maintenance of these extra security measures was not monitored and Individual B would rattle the gate and it would open allowing them to leave.

(6) You failed to report a safeguarding issue to the Responsible Individual.

11. A safeguarding referral was made on 25 July 2019 by the Responsible Individual about the failure of Mr Leonhardt to report another safeguarding issue. The substance of this referral was investigated at an unannounced visit by a Senior Practitioner and Contracts Monitoring Officer on 2 August 2019. This found that service users’ bedroom doors were locked with the people inside. There was a ‘thumb lock’ on the inside but given most of the service users had mental health issues, some lacking capacity, they may not have been able to exit their rooms in the event of fire. The Registered Manager did not report this issue to the Responsible Individual at the time of the visit.


12. Mr Leonhardt confirms his agreement to the facts set out in this statement.

13. Mr Leonhardt confirms that it is not his intention to work in the future in any capacity which would require him to be registered by SCW and that he wishes his name to be removed from SCW's register by agreement under Rule 9 of the Investigation Rules 2020. This statement of agreed facts has been prepared for that purpose.

14. If, contrary to his expressed intention, Mr Leonhardt should make an application for registration with SCW at a future date, he acknowledges that SCW may have regard to the contents of this statement when considering such an application.