Lindly House 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 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 provider was in breach of legal regulation in relation to risk management, the health and safety of people and safeguarding people from the risk of abuse.

This service scored 56 (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.

Window restrictors were not fitted where they should have been, which put people at unnecessary risk. Yet we were shown evidence that they were fitted at the provider’s other service. This meant that there was no shared learning between the 2 services.

The provider did not follow through on actions from their own fire risk assessment, as some required actions were left incomplete. This meant that oversight and accountability were not strong enough, meaning risks were not always managed properly and safety measures were not consistently put in place to keep people safe.

The registered manager reviewed incident and accidents that occurred and put measures in place to prevent them from happening again. Information was passed on to all staff verbally at the beginning of each shift. However, there was no written handover record, and no staff meetings took place to discuss how lessons could be learned and improvements made to the safety of the service.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always make sure there was continuity of care, including when people moved between different services.

Whilst some people’s health and care needs had been assessed and were being met at the service, one persons were not, and there was no clear evidence to show that the provider had assessed their needs and that they could meet those needs safely. Records did not demonstrate how the person’s risks and support requirements would be managed, and this affected their continuity of care. The provider was unable to show that appropriate systems were in place to support the person, particularly during transitions or when their needs changed.

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. One person told us they did not want to reside at Lindly House. We spoke with the registered manager, who confirmed this person had capacity to make decisions about their care, treatment, and support. However, there were no corresponding records between the social care team and the provider to evidence the person was lawfully residing at the service. We raised a safeguarding referral following the inspection to ensure the person was safe to remain at Lindly House. The provider had not recognised this as a potential unlawful restriction of the person’s human rights.

Staff we spoke with understood who and when to report potential incidents of abuse and the provider had responded appropriately when alerted to incidents. There were family members working together at the service. We discussed the whistleblowing procedure with the registered manager around these staff if there were concerns raised around their care practises with them. They told us they had not considered this. Following the inspection the provider sent us a risk assessment to ensure family members working together at the service had a clear route to escalate safeguarding concerns.

The provider did not always work well with people to understand and manage risks. Staff did not consistently provide care that was safe or supportive, and people were not always encouraged to be independent. One person who did not want to remain at the service was restricted, and their choices and independence were not promoted. As a result, the person was not always supported to do the things that mattered to them independently.

Other people were supported with their risks and independence with the support of staff. Staff knew people well and people had individual risk assessments which staff followed to keep people safe.

The provider had 2 pets which freely wandered through the home. One person told us, “I love the dogs they are great”. People had individual risk assessments in place due to their mobility needs and the potential risk of trips and falls due to the pets.

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.

The provider had not identified that window restrictors were not fitted throughout the service. They had failed to assess the risks associated with there being no window restrictors. We found rooms where windows opened sufficiently wide enough for people to be able to fall or jump out. The provider took immediate action to order window restrictors and began to fit them.

Other environmental checks were taking place regularly, such as the testing of hot water, and fire alarm and equipment tests.

The provider did not always make sure there were enough qualified, skilled and experienced staff. We looked at staff rotas and the management confirmed there was only 1 member of waking night staff within the service, Monday to Thursday and 2 at the weekends. The arrangement was that the nominated individual who lived next to the service would support if needed during the week. This would have meant the nominated individual would have had to enter a burning building in the event of a fire. However, we saw the provider’s fire risk assessment had been completed on the grounds there were 2 people in the building during the night-time hours. This meant that there were insufficient staff to keep people safe through the night in the event of a fire. Following our inspection the provider responded by increasing the staffing to 2 in the building every night of the week.

From our observations during the day, there were enough staff to meet people’s needs in a timely manner. People did not have to wait to have their care and support needs met.

Safe recruitment procedures were followed to ensure all staff were suitable to work in their roles. This included identity checks, appropriate DBS checks, confirmation of qualifications and experience, and obtaining satisfactory references prior to employment.

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

The service was clean and free from malodour. Staff used PPE and there were a sufficient stock of gloves and aprons available.

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

People had ‘as required’ PRN protocols which supported staff to be able to administer these medicines when people required it. Medicines were stored securely and administered safely by suitably trained staff.