Lyndhurst 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 assessment 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 provider was in breach of regulation in relation to premises and equipment.

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 provider had a proactive and positive culture of safety based on openness and honesty. Staff mostly listened to concerns about safety and did investigate and report safety events. There was an incident and accident log in place, and any learning from incidents was routinely discussed at team meetings.

The provider 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. For example, relatives described positive experiences when their family members moved in. One person told us, “The registered manager rang me before dad came in and she sounded really nice, so I felt that he would be okay.” People’s needs were assessed, and care plans were in place to support safe care delivery.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff 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 provider shared concerns quickly and appropriately. Safeguarding was taken seriously. Staff had received training and were confident in identifying and reporting concerns. People told us they felt safe. One person said, “I know the registered manager and I’m not afraid to say if anything is wrong.” Policies and procedures were in place, and staff understood their responsibilities.

The provider mostly worked well with people to understand and manage risks. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. However some improvement was needed. While staff were generally competent and people felt supported, care plans lacked detail in key areas. For example, diabetes management plans were vague and did not reflect people’s dietary needs. Also, 1 person’s bank card was used by staff without clear documentation, only verbal consent from the person. Risk assessments did not consistently reflect people’s capacity or preferences, and some language used was unclear. We raised this at the time with the registered manager and the provider. These risk assessments have since been updated.

The provider did not always detect and control potential risks in the care environment. They did not always make sure that equipment, facilities and technology supported the delivery of safe care. For example, we found uncovered radiators with dangerously high surface temperatures in communal areas, posing a burn risk. These were above the recommended temperatures. There were loose screws on the bathroom floor and some broken furniture in bedrooms. Some areas of the home were visibly dirty, including toilets and stair carpets, and the décor was in poor condition in some people’s bedrooms. We raised this with the provider who took immediate action and removed the risk. They also shared a home improvement plan with us around refurbishments in the home.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. Staffing levels were appropriate. People and staff consistently told us there were enough staff on duty. One staff member said, “Staffing is okay, people can go off, but we manage.” Recruitment processes were safe and staff described feeling supported and well trained. The service did not use agency staff, which helped maintain consistency in care.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Infection Prevention Control (IPC) practices were robust, with Personal Protective Equipment (PPE) available and staff trained. However, we did raise that some areas of the home required further cleaning. Some toilets were persistently unclean. We raised these concerns with the provider who took immediate action.

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 generally well managed, with blister packs used and no covert administration. However, we found minor issues such as missing opening dates on liquid medicines and eye drops, and 1 medicine recorded as not given. There was also a PRN medicine without a supporting plan. PRN medicine is medicines which are given as and when required. The registered manager addressed this straight away. Staff had completed competency assessments, and people told us they received their medicines as needed.