Letheringsett Hall

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.

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. Staff told us they felt confident in raising concerns. A staff member said, “I have no concerns and would report to management if I did.” The provider showed us a national incident that happened in a care home, the provider had shared and discussed this information in a staff meeting as an example of lessons learned. However, we found during our site visit that safeguarding concerns were always raised and reported to the relevant authorities.

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. Assessments were completed during the admission process, people’s wishes and needs were gained. However, these were not always reviewed on a regular basis to ensure they reflected people’s current needs. Staff worked effectively with healthcare professionals when they visited. However, we found that the provider did not always identify health needs that required a referral to a healthcare professional.

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 protecting their right to live in safety, and free from abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately. We found some incidents were not reported to the appropriate and relevant authorities. The provider did not have a clear understanding of which incidents were required to be reported. For example, 1 person had experienced numerous falls and whilst the service was putting measures in place to mitigate the risk, the falls continued and were not reported. Staff had received safeguarding training. Staff were clear on how to report concerns and how they would recognise signs of abuse.

The provider did not always work well with people to understand and manage risks. Care plans and risk assessments for associated risks were contradictory. For example, 1 person had a night assessment in place that stated that they like to wake between 6AM and 8AM, their night care plan contradicted this and stated that they liked to be woken between 5AM and 7AM. However, when we reviewed the care notes for 1 person, it was recorded they were being supported with personal care at 4AM. A moving and handling risk assessment stated that the person did not experience falls. However, we found records that the person had experienced numerous falls.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care. During our first site visit we found one of the ground floor fire exits blocked by equipment, therefore people could not safely leave the building in the event of an emergency. We found concerns with the Thermostatic Mixing Valves (TMV) not working effectively and hot water pipes were exposed in communal areas,people’s rooms and ensuites. We raised these concerns during our site visit with the provider. The provider mitigated the risks promptly regarding the fire exit and exposed pipes. However, on our second site visit one of the Thermostatic Mixing Valves (TMV) in a communal bathroom had not been resolved and therefore posed a potential scalds risk to people using the service.

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. They did not always work together well to provide safe care that met people’s individual needs. Staff were generally recruited safely and in line with the provider’s policies. However, during our assessment we identified that a volunteer was working at the service without the required pre‑employment checks. This meant the provider could not be assured that the volunteer was suitable to work with people using the service, which falls short of safe recruitment practices. During our formal feedback with the service, they informed us that they would be completing the appropriate checks for the volunteer to work in the service safely.

The service had an established staff team. One person said “I do feel safe here. You can call for help if you need to.”

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. During our site visit we found the home were recording temperatures for 3 fridges, however there were only 2 fridges in the home. We found a thermometer missing from one of the freezers and meals had not been probed for that current week. The cleanliness of the home was good in areas. However, we found 1 mattress to be stained and dead bugs on a windowsill. During our site visits, the provider rectified these issues.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. Medicines were stored safely and appropriately. Staff received training and medicines competencies. Staff were confident in administering in medicines and had a clear understanding of people’s medicines. Medicines audits were completed regularly.