Archived: Lyndhurst Residential Care Home

We visited the home with the healthcare professionals who had highlighted these concerns. We found that people received unreliable, inconsistent, unsafe and deficient care that exposed them to harm or the potential risk of harm.

Four of the 11 people living at the home had diabetes. We found evidence of poor diabetes management and control, which meant that were at risk of developing diabetes-related complications. We found that some people with diabetes had not been given adequate foot care, which put them at risk of complications such as peripheral vascular disease, which can result in pain, ulceration and, ultimately, amputation.

At the time of our inspection care staff from the home were responsible for the administration of insulin to people with diabetes. We found that there was a lack of clarity about which staff had attended training and had been assessed as competent to administer insulin.

We found evidence of inadequate pressure ulcer management. Healthcare professionals told us that people’s pressure ulcers were deteriorating rapidly and that staff were sometimes unaware that new pressure ulcers had developed. We also found that people were not supported to maintain adequate levels of hydration. Some people had very poor oral hygiene with no evidence that oral care had been provided.

We identified significant concerns in relation to the management of medicines. Medicines were not stored securely and the provider did not have a written medicines policy to provide guidance for staff on the safe management of medicines. There was no evidence that the provider carried out audits of medicines. There were no clear instructions on the dose of insulin to be administered to people with diabetes. There was no evidence that the provider carried out risk assessments for people who managed their own medicines. We found that that the records of medicines administered were not accurate. We observed that the provider did not follow appropriate procedures when recording the medicines that had been administered.

These concerns related to checks carried out on staff before they began work, the induction, training and support provided to staff and the action taken by the provider when risks to people's health were identified.

We found insufficient evidence that the provider had taken action to make the improvements needed.

The provider was unable to demonstrate that appropriate checks were carried out on staff before they began work. Some staff files did not contain evidence of criminal record checks whilst others did not contain satisfactory evidence of conduct in previous employment. Where staff files did contain references, we were unable to satisfy ourselves that the references were genuine.

The lack of information obtained about staff before they began work meant that the provider could not assure themselves that people living at the home were cared for by staff who were suitable to work with vulnerable adults.

We found that the provider had booked refresher training for staff in core areas and that some staff had had the opportunity to attend a one-to-one meeting with the provider. However we also found that significant shortfalls remained in the induction of new staff and the provision of opportunities for staff to discuss their training and development needs and to obtain qualifications relevant to their roles.

We found that the provider did not maintain accurate records to ensure that risks to people's health and welfare were identified and managed effectively. Some potential risks, such as inadequate nutrition and tissue breakdown, had not been assessed at all for some people. Where risk assessments had been carried out we found inconsistencies in calculating and recording. We also found that, where risks to people's health or welfare had been identified, there was no evidence that appropriate action had been taken to address these risks.

Relatives spoke highly of the care provided to their family members by care workers. One relative told us, 'They know my mum very well and make sure she's well cared for' and another said, 'They couldn't be kinder.' District nurses also provided positive feedback about the care provided by care workers.

At our last inspection we found that the provider did not have appropriate measures in place to reduce the risk and spread of infection. At this visit we found that that standards of infection prevention and control had improved.

We found that appropriate checks were not always undertaken before staff began work.

We found that some staff did not receive an induction when they started work and that staff did not have access to regular training, supervision and appraisal. Staff had attended training in core areas but refresher training in these areas was sporadic.

We found that risks to people were not always identified because risk assessments were not reviewed regularly or correctly completed. We also found that where risks to people's health had been identified through the risk assessment process, there was insufficient evidence to demonstrate that action had been taken to address these risks.

People said that they were supported to make choices about their daily lives, such as where and what they ate and how they spent their time. They said that their privacy was respected when care was being delivered or when they wished to spend time in their rooms.

People told us that they felt safe and well cared for at the home. One person said, 'I think it's fantastic. I'm very happy here'. The visiting relatives we spoke with said the quality of care their family member received was 'very good, excellent' and described the staff as, 'very caring.' One relative said of the home, 'It's comfortable and she [the relative's family member] likes it very much ' it's a home from home for her.'