Lisbeth Nursing 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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

This is the first assessment for this service. This key question has been rated good. This meant people were safe and protected from avoidable harm.
 

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.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

There were clear processes in place that enabled the whole staff team to learn from incidents, near misses, and any events within the service that highlight opportunities for improvement. Learning was shared promptly through daily meetings, handovers, and staff discussions, ensuring information was not delayed or overlooked. Memos for key updates and meetings were issued, which all staff were required to sign to confirm they read and understood the information which reinforced individual responsibility for staying informed and maintaining safe practice. These systems ensured that learning was embedded quickly, and actions were taken without delay.
 

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The registered manager undertook thorough pre‑assessments to ensure the service could meet each person’s needs before they moved in. Follow‑up assessments were then completed with people and their relatives once they had transitioned into the service, and again 4 weeks after moving in. This ensured that the most up‑to‑date information was captured, people’s needs were accurately understood, and any risks were identified early. These processes supported safe care, effective oversight, and continuity of support.
 

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People told us they felt safe living in the home. One person said, “I do feel safe, I can’t explain what it is - I just do.” Safeguarding was prioritised within the service. It was a standard agenda item in daily handovers and team meetings and was routinely discussed. Staff also had access to up‑to‑date safeguarding information, which supported their autonomy to make referrals directly to safeguarding teams when necessary.

Staff received safeguarding training, which equipped them with the knowledge and confidence to recognise the different forms of abuse and respond appropriately to concerns. During discussions, staff were able to clearly explain the signs of abuse and the actions they would take to protect people. One staff member said, “I report any concerns to management, and I am always looking at residents to see if they are ok, and whether there is anything I need to be concerned about. When there are any concerns, we get feedback and only today I have been given a team meeting memo, and everyone signs it and safeguarding is on there as a topic.”
 

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People had detailed risk assessments in place which guided staff to support them in the safest and most appropriate way. Where people had specific health conditions, such as diabetes, their care plans were clear, personalised, and tailored to their individual needs. This ensured staff had the information required to deliver consistent and effective care.
There were established processes for staff to report accidents and incidents, and these were routinely followed. Incidents were reviewed, and any required actions or learning were identified and implemented. Care plans and risk assessments were updated promptly when changes were needed, helping to maintain people’s safety and prevent recurrence of similar incidents.

We observed staff supporting people to move in a safe way in line with their assessed needs and staff were able to tell us about the actions they took to keep people safe.
 

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The environment was regularly checked and well maintained to ensure Lisbeth Nursing Home remained a safe place for people to live. Routine compliance checks were carried out on equipment and across the wider environment to ensure health and safety standards were consistently met. Any issues identified during these checks were addressed promptly, helping to maintain a safe, well‑managed setting for people and staff.
 

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

One person told us, “Mostly, there is always enough staff, and they always answer my buzzer quickly.” Staff told us they felt staffing levels were good and that they were well trained, which contributed to high morale and a positive working environment. Staffing levels were sufficient to meet people’s needs, and a dependency‑based staffing formula was used to determine required numbers. This was often staffed above recommended levels to ensure people received safe and timely care. The registered manager told us they regularly reviewed staffing to ensure it remained appropriate as people’s needs changed. Safe recruitment processes were in place, and all necessary checks were completed before staff began working at the service to ensure they were safe to work with people who used the service.
 

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

There were effective processes in place to support good infection prevention and control. The home was clean, well maintained, and free from malodour. Regular cleaning schedules were followed, and staff understood their responsibilities in maintaining high hygiene standards. These measures helped ensure the environment remained safe and reduced the risk of infection.
 

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

There were robust systems in place to ensure medicines were managed and administered safely. Staff were well trained in medicines management, which helped reduce the risk of errors and ensured people received their medicines on time and as prescribed.

Clear processes were in place for the safe storage and disposal of medicines, and regular audits were carried out to ensure these procedures were consistently followed. Where people required medicines at specific times, this was adhered to, and for those who needed their medicines administered covertly, appropriate plans were in place in line with legislation and best practice guidance.