Loyd 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

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 Requires Improvement. At this assessment the rating has remained Requires Improvement.

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 regulation in relation to reg 12 safe care and treatment.

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. Lessons were not always learnt to continually identify and embed good practice.

Lessons were not always learnt to continually identify and embed good practice, for example: previous concerns identified at the previous inspection such as missing opening dates on people's prescribed creams, reoccurred during this assessment, indicating lessons were not fully embedded. This was brought to the management's attention and rectified during this assessment.

Accident and incident systems were in place, but these had not been reviewed since July 2025. This indicates gaps in continuous learning.

Staff told us they were confident to escalate safety concerns to the management team.

We received mixed feedback from people and their relatives, one person told us, “They had raised the same concerns with staff “countless times” but felt that “nothing ever changes.” Another person said, "Absolutely.” when asked if they felt able to raise any concerns.

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 service. People’s care plans did not always contain enough or correct information. For example, not all care plans we reviewed contained information regarding people's medicines or equipment. They did not all contain preferred preferences of male or female carers to support with personal care, this meant staff were not provided with enough information to be able to support people in line with their preferences. We brought this to the attention of the management team who assured us all care plans would be reviewed.

We were made aware of somebody being in the service for 3 weeks and staff repeatedly asking for the care plan, but this was not in place. However, people all had hospital passports which provided basic information should the person to be admitted to hospital .

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

Staff had received safeguarding training and told us they were confident to raise concerns. The provider had a safeguarding policy in place. However not all staff knew how to access the policies, which may limit their ability to refer to guidance when required.

People and their relatives mainly told us they felt safe. One person told us,“yes and well cared for. I like it here quite a lot.” Another said, “Absolutely. I don’t have any complaints; it’s like a home from home.” Whilst another told us, “They feel safe most of the time (around 90%), but not with certain staff members, voicing they felt that some staff do not have their best interests at heart and “couldn’t care less.”

Not all of the people we spoke with were involved in the planning of their care and care plans required more input to evidence people's involvement.

Where required, people had Deprivation of Liberty Safeguards (Dols) in place or applied for. However, the management team were unable to evidence the chasing of an application made in 2020 which had still not been authorised. When this was brought to the attention of the management team, they assured us they would review all applications.

People's best interest forms and Mental Capacity Assessments required improvement to evidence people's involvement, appropriateness, revisited questions, signatures and review dates.

Systems and processes had not identified our findings during this assessment.

The provider did not 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.

People's care plans did not always contain enough or correct information for staff. For example, the service used the clinical waterlow tool (a healthcare assessment used to evaluate people's risk of developing pressure ulcers). However, care plans did not contain guidance on what the scores meant or actions to take. Additionally, 2 people who had pressure mattresses had not been weighed monthly as per their care plans, this meant the service could not be assured the settings were correct.

One person had an incorrect recording of food level on their care plan; however, they were receiving the correct level.

One person had a medicine listed that was not prescribed for them. We discussed our findings with the management team who assured us steps would be taken to address this.

People did not always have appropriate risk assessments in place for example the care plans we reviewed people who had prescribed flammable cream did not have risk assessments in place, these were put in place when discussed with the management team.

Monitoring charts for bowel movements, repositioning, food and fluid intake and personal hygiene were not fully completed. This placed people at risk of developing pressure ulcers, dehydration and poor hygiene outcomes. In one case a person had only received oral care once in 22 days and only 3 bowel movement recorded with no actions taken being recorded. Additionally, some of the toothbrushes we checked were dry. This was brought to the management teams’ attention during this assessment who told us actions would be taken.

Care staff had not completed falls training; this was booked during this assessment.

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.

We found the environment cluttered in corridors, due to lack of designated room for moving and handling equipment, putting people at higher risk of trips and falls, we discussed this with the management team who told us steps had been taken for the removal of equipment no longer in use. The home and people's rooms did not always appear clean; however, they were mostly free of odors.

People's wardrobes were secure in their rooms; however, we observed a free-standing wardrobe and stacked drawers which posed risks; these were removed after being raised with the management team.

We found no evidence of routine checks or oversight in place to monitor air mattresses. This was raised with the management team who assured us they would implement a system for regular monitoring.

The provider had continuity plans in place for emergencies such as loss of power; however, these required more information to ensure they were suitable for the service and to ensure safe service operation.

The kitchen had a control of substances hazardous to health COSHH risk assessment folder, however not all items were listed. This was brought to the attention of the management team who updated promptly.

The service had individual personal emergency evacuation plans for people (PEEP), however these needed updates; this was completed during this assessment.

Some of our findings were identified in the provider’s health and safety audit. However, we found gaps in recordings such as weekly environmental checks, monthly hot surface checks, and monthly sling inspections. This was discussed with the management team during this assessment.

These findings indicate there were areas requiring oversight.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.

People and their relatives mainly told us they were happy with the staff at the service; however, some people told us that it can be short staffed at times which can prevent them from accessing the community. When asked if people felt staff were well trained to support them, one person told us, "Yes, I think they do a marvellous job. It is remarkable how they look after (relative).” Another person told us: "A lot of the staff are agency, and care is not very good.”

Staff told us they felt they received adequate training but felt they were short staffed at times, and this prevented them to support people to go out when they wanted to. Confirming what people had told us.

We identified some staff still had gaps in their training, the management team clarified steps they had taken to address this. Staff had not been trained in areas such as falls and positive behaviour support, when discussed with the management team they assured us these would be implemented and when staff had completed positive behaviour support (PBS) these would be put in place for people who need them. However, staff completing delegated tasks, such as diabetes care, had received training and competency checks with oversight from the diabetic nursing team.

During this assessment we identified gaps in recruitment records, this was discussed with the management team who assured us of new systems which are to be put in place to help identify and address these.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

People and their relatives told us staff wore appropriate PPE. One person told us: “Yes, I have seen the staff regularly with PPE and masks as required.” However, another person told us,"(Relatives) room is filthy and never cleaned. I have had to wipe faeces off their bed and clean it from their nails as well. There is also syringes in with their [belongings]. I have raised this with them many times and nothing happens.”

Staff had received infection prevention and control training and told us they had adequate supply of personal protective equipment. However, we observed several people's rooms not to have dispenser soap or hand towels, we brought this to the attention of the management team, who took steps straight away to ensure all were in place.

Some staff told us the service needed to improve on the cleanliness, and they required further guidance from the management team what is required and who is responsible: for example, care staff or cleaning staff. Staff told us they felt some people would benefit from further encouragement to ensure their rooms were kept clean.

There were gaps in the cleaning rotas, and staff did not record when bed sheets were washed this was discussed with the management team that this would be put in place.

We noticed both microwaves were rusty, this was discussed with the management team, who replaced one immediately and ordered the second one.

First aid kits did not contain content sheets and were not checked regularly to ensure adequate stock was in place, during discussion the management team assured us this would be put in place.

Whilst the service still did not always appear clean throughout, the main kitchen was kept clean. With cleaning rota's being completed as well as temperature probe checks and fridge temperatures. However, these were not always completed in the chef’s absence. Food was generally stored hygienically, with food items having an opening date. However, this was not the case in the dining room fridge, and this was discussed with the management team.

We observed dishwasher tablets being kept in an unlocked cupboard alongside people’s thickeners. This was brought to the management team’s attention and was rectified immediately.

Provider audits had not identified all our findings during this assessment.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

Prescribed creams were still not being dated once opened, risking use of expired products. We were not assured people always received their medicines as prescribed. For example: People who were prescribed medicines to control stomach acid did not always receive these in line with the medicine instructions, as records did not show they were given before food and other medicines. This meant people were at risk of other medicines not being absorbed as they should to be effective. These issues were raised with the provider who arranged for staff to review their practices to prevent these risks.

Staff had received medicines training and the staff we spoke with gave good description of supporting people with Percutaneous Endoscopic Gastrostomy support. However, records did not evidence flushing was taking place as required or that people were having adequate fluid with their medication, this was discussed with the management team who took action to ensure this would be in place.

There were protocols in place for people's "when required"(PRN) medication. However, these needed to be completed in full to include information such as when appropriate to contact the GP, this was discussed during this assessment, and the management team assured us these would be updated.

The service had a medicines policy in place. However, we found this was not always followed, for example there were missing signatures with controlled medication, this had not been picked up on audits.

The service had no oversight to ensure the correct stock of medicines were in place, for example some of the medicines we counted were different to what the service had recorded on their electronic medication administration record (EMAR), we discussed this with the management team who assured us they would take actions to rectify this.

Food and drink thickeners were found in unlocked cupboards, posing a potential risk of people accessing and consuming these. This was addressed with the management team during the visit.

People's thickener had been opened but was not dated. One of these had been prescribed in 2024 and the persons care notes did not always evidence that they received their thickener as prescribed, this meant we were not assured the thickener was being administered safely and in line with clinical guidance.

People's care plans did not always contain lists of their medicines; this was discussed with the management team who assured us all care plans would be reviewed and updated as necessary.

Actions agreed from the previous inspection such as 'Ad-hoc routine checks on medication rounds to ensure staff are only administering one residents’ medication at a time.' Had not been implemented, indicating a lack of learning.