Lanercost House - Carlyle Suite

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 remained good. This meant people were safe and protected from avoidable harm.

This service scored 69 (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 listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Incidents and complaints were recorded and regularly reviewed by managers to identify patterns and trends. Learning from incidents and complaints was shared with staff during team meetings and daily handovers, helping ensure staff were aware of important updates and changes. Leaders monitored actions and progress to support improvements and reduce the likelihood of similar incidents occurring again.

Relatives spoke positively about being able to raise concerns about safety. One relative told us, “I feel confident going straight to management, concerns are always acted on. I always feel listened to.”
 

The provider worked well with people and other health and care services to maintain safe systems of care. They helped ensure continuity of care when people moved between different services.

The provider took a collaborative approach to safety. Relatives spoke positively about transitions into the service. One relative told us, “[Person] came from the hospital to [Lanercost-Carlyle Suite], it all went very smoothly”

Thorough assessments were carried out when people moved into the home. These involved the person where possible, their relatives and professionals involved in their care. This helped ensure information was accurate, up to date and shared appropriately. Emergency information packs were used to support safe transfers between services, such as hospital visits. Staff understood the admission process and told us they received the information they needed to support people safely.
Health professionals told us referrals were made in a timely way and communication from the service was clear and effective. One partner said, “Staff provide a clear clinical handover for the people receiving our care.”
 

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.
People were protected from abuse, neglect and discrimination. Family members told us they felt people were safe living at the home. One relative told us, “People working in the home are caring, kind and loving, I know [person] is safe here.”

Staff understood safeguarding procedures and there were systems in place to maintain clear records. Relevant statutory notifications were submitted to CQC. All staff had completed safeguarding training.

People can only be deprived of their liberty to receive care and treatment when the correct legal processes are followed. We checked whether the service was working in line with the Mental Capacity Act and the Deprivation of Liberty Safeguards (DoLS). The provider kept a DoLS tracker and applications had been made where appropriate. We found one person’s records contained conflicting information about whether their authorisation had been approved.
We also found some applications would benefit from being updated to reflect current restrictions for people. The provider demonstrated they had acted on this during the inspection.
 

The provider did not always work well with people to understand and manage risks.
Risks to people were not always clearly assessed, recorded and managed in a consistent way. For example, where alternative arrangements to a call bell were in place for a person, the reasons for this were not clearly recorded.

We found gaps in risk assessments for some people. One person who had previously presented certain safety risks did not have a corresponding risk assessment in place. Although the provider told us this risk was no longer present, records did not clearly demonstrate how this had been assessed or reviewed.
Some care plans contained unclear or conflicting information. For example, a person’s distress support plan included both improvements and worsening of behaviour without clearly explaining this or detailing how risks to others were being managed.

We observed 1 occasion where care was not delivered in line with the person’s care plan. One person was supported with eating in a way that did not follow their guidance, which stated staff should support from a specific side and ensure correct posture. This placed the person at potential risk. The provider responded immediately during the inspection and took action, including reviewing seating, retraining staff, updating support plans and holding a best interest meeting with family.
However, staff knew people well and demonstrated a good understanding of their needs. In practice, staff were often able to support people safely, even where records did not always fully reflect current risks or guidance.

Where care plans and risk assessments were clear, they demonstrated a person-centred approach to managing risks. This supported people to continue doing the things that mattered to them while maintaining their safety.

Some relatives told us they would like better access to their family member’s care plans and daily notes so they could be more involved in managing risks. The provider told us families could view a copy of their relative's care plan when they visited the home and were working on a solution to easier access that would meet data protection requirements. We also saw evidence that the provider acted quickly to address the concerns identified and had already made improvements during the inspection.
 

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

There were effective systems in place to monitor and maintain safety across the environment. Regular checks were carried out on the premises and equipment, including water safety, electrical systems and general maintenance. Staff carried out routine checks of bedrooms, equipment and the wider environment to ensure safety was maintained. Records showed these checks were completed consistently and any issues identified were addressed promptly.

Equipment used to support people, such as hoists, were serviced and inspected in line with regulations. We saw equipment was appropriately maintained and clearly labelled.
Fire alarms were tested weekly, and evacuation procedures were clearly documented. Staff told us they took part in regular fire drills, which helped ensure they knew how to respond in an emergency. Fire safety equipment was in place and regularly checked.
 

The provider made sure there were enough qualified, skilled and experienced staff to meet people’s needs. Staff received effective support, supervision and opportunities for development, and worked well together to provide safe care that was tailored to individuals.

Safe recruitment procedures were followed to ensure staff were suitable for their roles. There was a comprehensive programme of training, which supported staff to deliver care safely and effectively. This included training in areas such as positive behaviour support, helping staff to understand and respond appropriately to people who may express behaviours as a way of communicating their needs.

Staff worked collaboratively to provide safe, person-centred care. They told us they received regular supervision and one-to-one support and spoke positively about the support they received from management.

Feedback we received from relatives indicated mixed feelings about staffing levels. A relative told us, “More staff at nights would be good. But staffing levels Monday to Friday are fine though often stretched when carers are off sick or on holidays.” With others telling us, “I’ve never though that there wasn’t enough staff” and, “Yes, there certainly is enough.”
The providers rotas and dependency tool indicated that there were enough staff to meet people’s care and support needs.
 

The provider assessed and managed the risk of infection. They had systems in place to detect and prevent the spread of infection and shared concerns with relevant agencies when needed.

The environment was clean and well maintained. Staff wore appropriate personal protective equipment (PPE) and had access to sufficient supplies. Regular infection prevention and control (IPC) audits were carried out, and staff had completed training to support safe practice.

Processes were in place to manage outbreaks, and information was shared promptly with appropriate agencies. Food was stored, prepared and handled safely, and records showed food temperatures were maintained within safe limits.

Relatives spoke positively about cleanliness. One relative told us, “It is extremely clean.”
 

The provider did not always ensure medicines were managed safely or that systems were effective in identifying and reducing risks.

We found gaps in risk assessments relating to medicines. For example, people prescribed paraffin-based emollients did not initially have appropriate risk assessments in place, although this was addressed during the inspection. One person receiving blood thinning medication did not have a related risk assessment, despite this being in place for others on similar medicines.

Records were not always accurate. For example, a body map for topical applications had been placed in the wrong person’s record. In addition, a person who was prescribed medication for constipation did not have clear guidance in their care plan about when the medicine should be given or what symptoms staff should look out for. This information was detailed in their PRN (when required) protocol, but this was not always accessible to staff. Although bowel charts were in place, there were gaps in recording, and it was not clear what action had been taken in response.

Medication audits were taking place but were not always effective in identifying these issues.

However, most aspects of medicines management were carried out safely. Medication administration records were clear and completed at the time of administration, and medicines were stored in line with best practice. Controlled drugs were stored and recorded appropriately. People receiving covert medicines had clear care plans in place, and PRN protocols provided guidance on when medicines should be given.

One medication error identified during the inspection was promptly investigated and addressed.

The registered manager and regional director provided evidence the concerns identified had been addressed following the inspection.