The Lawn Residential Care 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.
At our last inspection we rated this key question requires improvement. At this assessment the rating has remained 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 people’s safe care and treatment and governance at the service.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service listened to concerns about safety and investigated and reported safety events.

People and their relatives told us they felt comfortable raising any issues directly with staff or the registered manager and felt their concerns will be addressed.

The registered manager told us lessons learned were reviewed and information shared with staff through handovers, during staff meetings and supervisions to prevent recurrence.

Relevant parts of people’s care plans and risk assessments were updated following incidents, for example following a fall. Records confirmed incidents and complaints were investigated and reported. This meant the processes in place were reviewed and amended accordingly to support and improve care delivery.

The service 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.

People and their relatives told us they felt the service communicated with health and social care professionals when required.

Relationships between the service and health and social care professionals were established and operated well. Feedback collected during the inspection was positive. A health and social care professional said, “We have a good working relationship with the service.”

The service had a summary of people’s needs and used an electronic care planning system. This meant relevant documentation was easily available in case of an emergency hospital admission.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They 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 service shared concerns quickly and appropriately.

People told us they felt safe living at the service. A relative said, “I feel that [family member] is safe and well cared for at the service.”

Staff told us they knew how to raise concerns with the registered manager and felt confident to do so. A staff member told us they would speak with their immediate supervisor first before speaking with the registered manager. However, this depended on the seriousness of the concern they had. Staff were also aware they could report any concerns they had externally to the local authority or CQC. One staff member said, “We are providing care and the safest space for people.” Another staff member told us they felt people were safe living at the service due to various equipment used, including sensors to alert staff when a person was mobilising unaided.

Staff received training in safeguarding, and the provider had an up-to-date safeguarding policy in place. Records showed safeguarding concerns had been raised to the local authority as required. The provider held regular meetings with other services, external experts and representatives of relatives to discuss and review safeguarding concerns and ensure lessons learned were embedded into practice. The service regularly monitored complaints, medicines errors, pressure ulcer management, and falls. This meant safeguarding was not treated as an isolated compliance task but as an integral part of quality assurance and continuous improvement.

We observed staff worked in safe ways, for example, when supporting a person to transfer from a wheelchair to a chair using a mobility aid.

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 Mental Capacity Act 2005 (MCA). In care services, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA, whether appropriate legal authorisations were in place when needed to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met. All legal applications had been made in accordance with DoLS. This meant people’s rights were fully respected. The registered manager had oversight of DoLS applications.

The service did not always work well with people to understand and manage risks.

Staff told us they knew people well. However, people’s care plans were inconsistent and contained conflicting information. This meant they were not always reflective of people’s support needs.

For example, some care plans contained conflicting information relating to people’s mobility needs and their personal emergency evacuation plans (PEEP) were not reflective of the level of support a person would need to evacuate safely in case of a fire. This meant people were at risk of avoidable harm in case of an emergency evacuation.

The provider responded to our feedback and started the process of reviewing all care plans, including PEEP information.

The service 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.

People told us they liked their bedrooms. A person said, “The room is beautiful and comfortable.”

Staff told us they knew how to report concerns relating to the environment.

The service implemented some safety measures, such as covers on the radiators and window restrictors.

However, the physical environment was not always safe. For example, some bedrooms had portable heaters which the use of was not individually risk assessed. Some fire doors which should have been locked, were left unlocked and therefore accessible to people. In response to our feedback, the provider updated signage to some doors to help prevent a recurrence.The service had 2 kitchenette rooms with electrical equipment in them, such as kettles, toasters and microwaves. These were opened to everyone and not risk assessed. On 2 occasions we found the kitchenette doors opened, with the cooking equipment on and hot to touch. The provider responded to our concerns quickly by introducing combination locks on relevant doors. This reduced the immediate risk of harm to people.

We found 1 cleaning product, which posed a risk of irritation to eyes, had not been securely stored and was accessible to people.The provider removed this, therefore removing the immediate risk to people’s health and safety.

People had individualised risk assessments, however environmental risk assessments did not ensure people were safe from avoidable harm. Although people had individual choking risk assessments in place, there was no consideration for risks from choking hazards, including readily available food items. The provider removed the choking hazards and completed relevant risk assessment.

The service had regular health and safety audits and catch ups, however these were not effective in identifying the concerns found during this inspection.

The service made sure staff worked together to provide safe care that met people’s individual needs.

People and their relatives were complimentary about staff. One relative said, “Staff are very well trained at the service.”

Training records showed staff had the necessary training, skills and knowledge to carry out their roles.

Staff confirmed they had regular supervisions and staff meetings. Some staff we spoke with felt there were staff who did not do all that was expected in their role. They felt other staff members had to pick up extra tasks to ensure they did not get missed.

Recruitment procedures were in place to ensure the required checks were carried out on staff before they commenced their employment. This included enhanced Disclosure and Barring Service (DBS) checks for adults. DBS checks provide information including details about convictions and cautions held on the police national computer.The information helps employers make safer recruitment decisions.

The service assessed and managed the risk of infection. Cleaning staff maintained a constant presence within the service.

One relative told us they spoke with a staff member in relation to their family member’s room needing additional cleaning. This was addressed quickly, and the room was clean at their next visit.

The service had an up-to-date infection control policy in place. Staff received training in infection control techniques and were observed to use Personal Protective Equipment (PPE).

At the time of the inspection the service held a food hygiene rating of 5 which meant hygiene standards were very good and fully comply with the law.

Records confirmed all areas were cleaned regularly.

The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Medicines were not always managed safely. We found recording errors in the controlled drug’s books. The stock for controlled drugs was correct.In addition, we found some creams in people’s bathrooms did not have legible prescription labels on them. The provider was not working in accordance with their policy. Some creams were not dated upon opening, however dates were recorded on people’s medicine administration records. One homely remedy was being used 8 months after it should have been disposed of. During the inspection a staff member without necessary administration training administered medicines to 3 people. The provider did not have a system in place to ensure staff were supported when administering medicines.

This meant we could not be assured people received their medicines safely and as prescribed.

The registered manager responded promptly to our feedback. A new system was introduced to reduce the likelihood of prescription labels becoming unreadable. Creams without opening dates on them were disposed of and replaced with new ones, which were dated upon opening. The homely remedies which should have been disposed off, were removed and a GP was contacted. The provider ensured staff member who administered the medicines, received the required training and was observed administering medicines.

The service completed regular medicine audits. These were not effective and failed to identify and assess shortfalls we found during this inspection.

A staff member told us what steps they would take in case of a medicine error. These included contacting an out of hours service if required, competing incident form and informing the person affected.

Relatives and people did not raise any concerns regarding medicine management during our inspection. Comments included, “Stocks of medication are kept up to date, and there have been no problems,”, “As far as I know all the medicine is taken,” and “Staff ask permission before giving medicines, they tell me what they are for. I would ask if I didn’t know what it’s for.”