Lindisfarne Crawcrook

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 acted on safety concerns and reported incidents. Managers investigated what happened, shared learning and made changes to reduce future risks. Safeguarding enquiries and environmental issues led to updated care plans, increased observation levels and other actions to prevent repeat incidents.

Leaders encouraged improvement, and staff understood how learning was applied in practice. One staff member said, “Learning outcomes are shared with staff in face‑to‑face meetings, team updates and clinical governance 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. Staff followed a structured approach to admission and discharge, and handovers supported continuity of care. One relative said the transition into the service was “as smooth as it could reasonably have been”.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff focused 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, and staff documented investigations clearly, with statutory notifications submitted correctly. Where allegations were unsubstantiated, evidence supported these decisions. When concerns were upheld, the provider implemented improvements such as increased monitoring, staff retraining and strengthened reviews of care plans. Relatives generally felt safe to raise concerns with one telling us, “I do feel listened to when concerns are raised.”

The provider worked with people to understand and manage risks in ways that reflected their needs, preferences and circumstances. Staff provided care that was safe and supportive, and encouraged people to do the things that mattered to them.

Staff completed detailed assessments of clinical, behavioural and environmental risks, and updated these when people’s needs changed. They promoted positive risk‑taking to support independence and understood people’s fluctuating capacity. One staff member said, “I always ask for consent before providing care… if someone cannot make their own decisions, best interests decisions are followed.”

The provider did not always detect and control potential risks in the care environment, and they did not always make sure equipment, facilities and technology supported safe care. Environmental risks included missing or shortened pull cords, chipped handrails exposing bare wood, and unlocked clinical waste bins. There were also damp odours and worn or unclear signage and fixtures. Some relatives previously raised similar concerns.

The provider took immediate action by repainting handrails, ordering replacement pull cords, escalating window‑restrictor checks and reinforcing waste‑management practices. While this showed a quick response, the number and type of issues demonstrated that routine checks were not always effective or applied consistently.

Staff recognised the building needed improvement. One staff member said, “The building could do with some updates. Equipment needs better maintenance.”

The provider made sure there were enough qualified, skilled and experienced staff who received effective support, supervision and ongoing development. Staffing levels were appropriate, and rotas aligned with the dependency tool used to plan cover. There were enough staff on duty to meet people’s needs, and staff said they felt supported. One staff member said, “I feel well supported by management and senior staff.”

Some relatives said staff responded more slowly during busy periods or at weekends, which reduced oversight at times. Despite this, staffing during the visit was safe and responsive, and staff worked well together to deliver care.

We shared these findings with the provider to strengthen monitoring and weekend staffing arrangements and ensure consistent oversight across all shifts.

The provider did not always assess or manage infection risks, and staff did not consistently detect or control the risk of infections spreading. Staff did not always identify, escalate or manage concerns promptly, which increased the likelihood of infection transmission. Waste‑management issues included unlocked clinical waste bins that posed a contamination risk. During a recent influenza outbreak, leaders delayed escalating concerns to the local authority and obtaining antiviral medication.

The provider took action by reinforcing bin‑locking procedures and reviewing waste‑disposal arrangements. Although this showed a prompt response, these issues demonstrated that routine checks and escalation processes were not always effective.

The service had infection prevention and control policies, trained staff and regular cleaning schedules, and domestic staff were visible throughout the home. One relative said, “Overall cleanliness is very good… domestic staff present during every visit”.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.