Lynden Hill Clinic

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. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. The service was in breach of legal regulations in relation to safeguarding and staff recruitment.

This service scored 47 (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 did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.We found multiple incidents records that had not been fully and consistently completed. We considered this under the question whether the service was well-led. We were not assured these were completed in line with provider's policy to support people's wellbeing and safety monitoring. These events were not reviewed to identify further risk mitigation for people and update their records accordingly. The registered manager did not ensure incidents and accidents were thoroughly reviewed to help identify themes or trends that would require further action to be taken. For example, there were multiple falls happening, however the staff told us the management was collecting the information but unsure what was done with it.There was little evidence that the cause of accidents and incidents had been investigated to help ensure actions would be taken to prevent recurrences. The registered manager did not demonstrate that the duty of candour was followed when completing different investigations. People and/or their relatives were not always kept informed or provided with apologies and updates in both written and verbal formats.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.The registered manager explained how they prepared for admissions including gathering information from people before and after they came to the service. The registered manager said the nurses and physiotherapist would assess and record all the information about people and also they would meet the registered manager. However, our findings did not reflect this information given. People and relatives were somewhat involved, informed and supported by the registered manager and the staff team. People were not always sure if they had any plans of care. People’s records lacked details about individual needs, health and wellbeing, and any other information important to people. From the records reviewed during the visit, it was not always clear if professionals were contacted appropriately and in a timely manner to support people with medical needs and ensure continuity of care. For example, one person became unresponsive. Once they had first aid provided, it was not clear if any further advice was sought from any clinicians to ensure the person was safe and not at risk of further harm. Another person had a suspected hip fracture, but clinical and medical support was not sought until the next morning.The registered manager did not ensure they had regular meetings or discussions with the staff team about people’s needs, any issues were picked up in a timely manner and addressed, and staff informed what should be done. Due to the nature of the service, people were coming and leaving the service on a regular basis, but there was no real structure established to ensure the service was running smoothly.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.The registered manager did not ensure the system in place to protect people from abuse and improper treatment was used effectively. We found incidents where safeguarding alerts were not raised to ensure they were investigated properly. By failing to inform the relevant authorities of these allegations of abuse, this placed people at risk of ongoing harm or abuse. As part of their role, staff must receive safeguarding training that is relevant and suitable for their role. We did not have evidence to confirm all staff had completed this training. Some staff told us the steps they would take if they had any concerns. However, our findings did not support the registered manager and the staff were fully aware of procedures to follow thus people were put at risk of harm.Although the registered manager responded to information given and raised it with the local authority, this was identified during our assessment and not through the provider's own governance checks. Thus, we could not be assured this practice would be sustained.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). The registered manager noted they would not accept people who may need DoLS. There was no one who needed to have any other restrictions in place.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. We considered this under the question whether the service was well-led regarding having good oversight of people’s needs and risks with supporting records in place.Provider was using an online system to records people’s needs, support and risks. However, the risk assessments tab was empty at the time of assessment and it was confirmed by the clinical lead there were no other care plans or risk assessments than the ones on the platform. We were not able to see consistent risk assessments being in place in relation to different aspect of people’s care and to support effective risk mitigation. For example, one person had a spinal procedure. However, no moving and handling risk assessment had been completed, despite the person needing aids and staff for assistance. Moreover, there was contradictory information in regard to the aid the person needed to use during moving and handling tasks. The person had a wound, but the body map was blank to indicate the starting point for healing and ensure it was monitored effectively. There was a note to remove staples, but the date was blank. Another person’s information from hospital noted they were at risk of falls, but we identified there was no clear information recorded about how this person should be supported to manage the risk of falls to ensure safe mobility. People who were at risk of falls also had hourly checks. However, this was a general rule rather assessing people so they had time-specific checks to ensure safety.Some people came with medicine such as blood thinners however it was not clear if the risk of taking such medicine was considered and assessed.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.Maintenance staff were helpful and knowledgeable but openly admitted that records were difficult to maintain. The organisation of maintenance records was not consistent and records could be difficult to find to ensure good oversight. Not all maintenance records were completed and we were told some records needed “updating.” For example, fire safety records were not maintained regularly. Fire risk assessment was not updated since January 2024 as per risk assessment’s recommendation. Fire equipment checks and drills had not been recorded regularly to ensure good fire safety including staff and people being able to evacuate effectively. However, maintenance staff told us the work was being completed as scheduled.The registered manager confirmed call bell audits were not conducted. They said, “The maintenance staff monitor the system.” This meant information relating to staff response time was not analysed. We asked staff about call bell response times. One staff member said, “We are generally pretty quick, but it depends on what time of the day it is. In the mornings we are busier, so it can take a little longer.” This information could be used to improve the service if call response times were audited and analysed.People were positive about support from staff to ensure their safe environment. People said, “The staff help me with maintaining my safety with the equipment” and “The staff are very careful and one thing I noticed is that they know what my limits are before I do, which is reassuring.”

The provider and the registered manager did not make sure all staff qualified, skilled and experienced to provide care and treatment. They did not always make sure staff received effective support, supervision and development. We considered this under the question whether the service was well-led. Staff did not always work together well to provide safe care that met people’s individual needs.We reviewed the training matrix that noted a list of core topics. However, it was not clear which staff completed what training. It only noted some percentage of enrolment, so it was difficult to determine the completion rate from this information. The clinical lead explained they were working on assessing staff’s competencies such as medicine, moving and handling, as it was not done previously. Supervisions and appraisals were not happening regularly, and again, the clinical lead told us they were working through it as part of their role. Staff gave us mixed feedback about the support from the management and senior staff. This indicated some improvements were needed to ensure more positive and confident communication between the registered manager and the staff team.The provider could not assure us all the staff had the required training and competencies to be able to support people and to ensure they understood their different needs. This put people at risk of being cared for incorrectly or not according to their needs or conditions they may have or achieve good outcomes.

The registered manager did not always ensure all required recruitment checks and information were gathered before staff started work. We found missing information such as records of full employment history and explanations of gaps in employment; information on evidence of conduct from a previous employment working in health and social care. Records did not include information of the verified reasons why the previous employments ended. The registered manager did not ensure they carried out checks for the right to work in UK. We found the registered manager did not always ensure Disclosure and Barring Service (DBS) checks were carried out correctly before staff started working at the service. By failing to obtain all required recruitment information, the registered manager put people at risk of being supported by unsuitable staff.

The registered manager told us how they managed and reviewed staffing numbers according to the needs of people staying at the service. People told us they were happy with staffing and their requests were responded in time. People said, “I do not feel rushed at all. I think there is enough staff here” and “[Staff] come here very quickly.Yes, they do [complete all the tasks]. So far [staff] have helped me with all my needs.”

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.People were protected as much as possible from the risk of infection because premises and equipment were kept clean and hygienic. The service had a dedicated staff team to ensure they maintained appropriate infection prevention and control. The service assessed and managed the risk of infection. The provider had policies and procedures regarding infection prevention and control (IPC) and to monitor practice. Staff used personal protective equipment (PPE) appropriately and when required. People confirmed the staff were using PPE and they did not have any issues with cleanliness of the service.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. We considered this under the question whether the service was well-led in regard to having oversight of management of medicine and supporting records. We reviewed records for management of medicine and the clinical room.We found some out of date equipment such as syringes, testing strips, stockings, bandages, and barrier cream. This was not picked up during stock checks or medicine audits.We found one specific medicine was not signed out after the person left the service. Staff were carrying out checks for temperatures, medicines and equipment at each shift. However, the records had many gaps, which did not ensure required checks were carried out.People had different ‘when required’ (PRN) medicines to manage ailments. PRN protocols did not have personalised details regarding each person and their needs; the doses did not always match in the protocol and medicine administration record (MAR) sheet. The protocols did not include clear information about how people could indicate they were in pain and when people had multiple PRN medicine to treat an ailment, how to manage those correctly. When staff gave PRN medicine or did not have their regular medicine, they did not note the rationale for this. There was specialised medicine to be administered to people as PRN such as oxygen, glycogen,enema and nebulisers. However, there was little information about the process on how to manage it and keep records for when people needed such treatment. Staff were not all trained and checked as competent to complete these tasks. Staff used a form to note daily gaps in MAR sheets, but it was not always clear if those gaps were investigated.

People told us they were happy with the way they were supported to have their medicine including requesting any pain management medicine. They felt staff involved them in planning of their medicine management.