Lansdowne Road (67-71)

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 rating inspection (publication date 10 October 2023) we rated this key question Requires Improvement. At this inspection the rating has changed to Good. This meant people were safe and protected from avoidable harm.

This service scored 66 (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.

Relatives confirmed they were informed of when incidents occurred and had no concerns how incidents were managed. A relative said, “There have been no incidents/accidents recently, when these have arisen on the odd occasion in the past, staff are straight onto it and keep me fully informed.” Another relative said, “I am made aware of any incidents straight away. I have no concerns about safety, no complaints have ever been made, I would contact the management if I had any issues.”

The provider had improved its incident management systems and processes. Enhanced analysis and oversight, together with better staff communication procedures, had a positive impact on the provider’s learning culture. Throughout the inspection, the management team and staff were open and honest, confirming a positive staff culture.

In addition to the registered manager, all incidents were reviewed by senior managers, including the provider’s quality team. This ensured greater oversight that actions to manage and mitigate risks had been completed and lessons learnt.

Staff confirmed they were well supported when incidents occurred. They told us that the overall frequency of incidents had reduced, which they attributed to increased activities and structure, completion of training in positive behavioural support, and some people receiving additional staff support.

Staff also told us how communication and information sharing had led to positive outcomes in the management of incidents. This included having a de-brief and huddle meetings following significant incidents to share important information. A staff member said, “Incidents are all recorded, and the management review the incident record, they speak with us, and any learning is recorded, and we must read and sign to confirm we've read and understood. The management team are very supportive.”

Meeting records such as staff daily handovers, daily heads of department and staff meetings, confirmed incidents and any learning were regularly discussed with staff.

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. However, we identified some improvements were required in the provider’s internal systems and processes to ensure people received consistent safe care.

Procedures for sharing important information with others required improvement. Staff had access to an ‘emergency grab sheet’ folder used to share important information with ambulance and or hospital staff, to support consistently and continuity of care. We found this folder had 5 of these emergency grab sheets missing. This had not been identified by the provider’s ongoing monitoring and may have impacted in a delay in important information being shared easily and quickly. We discussed this with the management team who immediately acted and printed the required documents and added to the folder. They also told us they would review and amend their daily checks to reduce this from happening again.

Follow up to ensure health referrals by external health professionals had been actioned needed improving. From reviewing a sample of people’s support plans, we identified when the GP was asked to make a referral to external healthcare professionals for further assessment, support or guidance, this had not always been monitored or followed up by the management team. We identified two examples where the management team had understood the GP had made referrals, but following our enquiries it was established these referrals had not been made. Whilst no harm had come to people, and the registered manager took immediate action and followed this up with the GP during the inspection, this had not been identified by internal monitoring procedures.

The provider had a transition procedure for people transitioning into the service and leaving. People received bespoke plans dependent on their individual care and support needs. Staff confirmed people’s known care and support needs and risks, were shared with them before people moved to the service. However, we identified an example where the provider had not ensured all staff had completed specific training to meet the known risks a person could present with when they moved to the service. This had not had a negative impact on the person, and the provider assured us procedures would be reviewed to ensure this does not reoccur.

The management team had developed overall positive working relationships with external professionals

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.

People told us they felt safe living at the service. A person said, “I think the staff here are doing a great job, I feel very safe living here.” Relatives raised no concerns about safety and reported they believed their family member was cared for safely.

Staff had received ongoing safeguarding training and had access to the provider’s safeguarding policies and procedures. Staff demonstrated a good understanding of their responsibilities to protect people from abuse and avoidable harm. A staff member said, “Any unsafe practise is reported to the management team straight away. We also have a whistle blowing policy which I've not used but I'd be confident to do so. Safeguarding is remembering that we have a responsibility to ensure that people are protected at all times from any harm or abuse.”

People were supported to understand what safeguarding means and how to report any concerns about abuse. The provider had made safeguarding information available in easy read formats for people. Safeguarding was discussed with people in resident and keyworker meetings.

Local multi-agency safeguarding procedures were known, understood and followed.

Incidents reviewed confirmed where safeguarding allegations, incidents or concerns had occurred, these had been reported to the local authority and CQC as required.

People were protected lawfully in line with the Deprivation of Liberty Safeguards (DoLS). The provider had a DoLS policy and procedure, and staff had received required training. DoLS care plans informed staff of the authorisation and expiry date and details of any conditions. Where conditions had been made, we found these had been met.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Whilst risk assessments were in place where the person had an identified area of risk, we found further improvements were needed. Risk assessments did not always include control measures to reduce the risk. Internal monitoring procedures had not identified the shortfalls we identified.

For example, a person was at risk of falls. Guidance for staff lacked details of what staff should do in the event of the person falling. Another person was at risk of choking, again there was a lack of guidance of what staff should do if the person choked.

However, no person had come to harm, and we found staff to be knowledgeable about people’s individual risks and how to manage and mitigate these. Staff clearly advised us of the actions they would take to respond to these risks. This therefore indicated a recording issue. We spoke with the registered manager who took immediate actions to make improvements to staff guidance.

People and or their relatives were involved in discussions and decisions about how risks were managed. People met with their keyworker (a named staff member with additional responsibility of meeting people’s individual needs) monthly. This included discussions about how their care and support needs were met. A relative said, “I am very much involved with my family members help and support, I always try and attend annual reviews.”

Staff had received positive behavioural support (PBS) training and were positive about this training and the impact it had. This is a person‑centred approach that aims to improve quality of life by understanding the reasons behind behaviours that are described as challenging and supporting people to develop positive alternatives. PBS support plans had been developed, and these were found to be supportive to staff, about important information of how to safely and effectively support people during periods of increased anxiety.

Staff were trained in a recognised and accredited PBS framework. They used restrictive practices only as a last resort, preferring proactive strategies like redirection. Behavioural support plans and risk assessments outlined how the framework could be applied safely when necessary. Staff were able to describe how and when they would use this training and emphasised this would only be used as a last resort They gave examples of other strategies such as redirection, diversion, reassurance which they found much more effective.

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

People had personal evacuation plans (PEEPs) in place in the event of a fire. However, these did not always specify the level of staff support required, such as whether 1 or 2 staff members were needed. This could lead to delays or confusion during an evacuation. However, staff confirmed they had completed fire drills and from speaking with staff, they were able to advise of people’s support needs. This included a person who required ear defenders. An emergency grab bag provided staff with information and items to keep people safe, we checked this and found it including the ear defenders as described to us.

Our observations of a sample of wardrobes in people’s bedrooms found they were not consistently secured to the wall, presenting a potential safety hazard. The registered manager told us they were aware of this, and the maintenance team were in the process of securing these. Following the onsite inspection, the registered manager confirmed this has been completed.

The provider had relevant health and safety policies and procedures to ensure the service, premises and equipment were serviced, maintained and monitored. This included a daily walk around that included visual checks on health and safety, any shortfalls were recorded and action taken. Risks related to fire safety and legionella, a waterborne bacterium that can cause serious illness, were assessed, mitigated, and monitored. Staff had received fire safety-related training.

The local authority had completed an audit visit in November 2025. This audit report showed the provider was compliant with the local authorities’ expectations in health and safety.

The premises were secure. People had access to a smoking shelter, outdoor seating and lawn and flower beds.

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. However, before our inspection we identified that not all staff had completed training in a particular topic that was a known risk to a person.

During the inspection, we were assured that the staff supporting this person had relevant training and experience to provide safe care. The person had not come to harm despite not all staff having completed training as required. External professionals praised the staff and provider’s approach to maintaining this person’s safety. The provider confirmed they had learned from this situation and would review staff training prior to new admissions to ensure all staff have the necessary knowledge and competency.

People were positive that there were enough, competent and experienced staff. A person said, “Staff understand me and my needs very well, there are always enough staff around to help me if I needed it.” Another person said, “I think the staff here are doing a great job, I feel very safe living here, there are always enough staff around to support me.”

Relatives were equally positive about staff availability. A relative said, “I am satisfied at the staffing levels, and feel they know my family member’s needs very well.”

Staff raised no concerns about the deployment of staff. They told us there were always enough staff available, and they received regular training and opportunities to discuss their work, training and development needs. The staff training matrix confirmed overall training compliance was over 94%. Records also confirmed staff received an annual appraisal and regular opportunities to discuss their work, training and development needs.

A staff member said, “I have no concerns at all, people get their allocated additional hours, I feel safe working here, this team really work together 100%.” Another staff member said, “Supervisions are regular. I think they are important and helpful, my last one was last week and I really enjoyed it, it was lovely, gave me much more confidence.”

Staff were recruited safely, with appropriate checks completed before employment to ensure only suitable candidates with the right skills and experience were appointed. New staff received induction training, which included shadowing experienced colleagues.

Our observations found there were sufficient care staff available, and the staff rota and allocation reflected the staffing available. Care records also confirmed how people received their additional commissioned staff hours.

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. However, we found the service was not consistently clean and there was a malodour during the two days on site.

The management told us and records confirmed, concerns were identified with cleanliness and hygiene of the service in August 2025 and a deep clean was completed. Whilst improvements were made these had not been sustained.

Whilst cleaning records and additional daily logs confirmed that cleaning tasks were completed, improvements were still required. We concluded that the absence of housekeeping staff at weekends, combined with the size of the service and the needs of the people living at the service, impacted the provider’s ability to maintain sufficient cleaning and hygiene standards. We discussed this with the management team who agreed the deployment of housekeeping staff needed to change. Following the inspection, the registered manager confirmed 7 day housekeeping cover would be implemented in January 2026.

The provider had an up-to-date infection prevention and control policy, and staff had received relevant training.

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.

People told us they received their medicines when they needed and at regular times. Relatives raised no concerns about how their family member were supported with their medicines.

Medicines were managed in accordance with best practice guidance. Systems and processes, including management oversight, were in place to continually review and monitor how medicines were managed, and action was taken when medicine errors occurred. The provider’s internal quality and compliance audit completed during the Summer of 2025 identified some shortfalls with the management of medicines. Improvement has been made, and we found medicines were ordered, stored, administered and returned safely.

Staff responsible for managing medicines had received training in the safe handling of medicines, and their competencies were regularly assessed. We observed a medicine round and saw that medicines were administered safely and effectively.

We were aware that not all-night staff were medicines trained. However, the provider had an oncall procedure whereby a trained medicine staff member could be called upon if required. Records reviewed showed since January 2025 there had been 5 occasions when oncall were called upon, this confirmed there had been no negative impact on people. The registered manager told us they were in the process of increasing night medication trained staff.

People’s care records confirmed their medicines were reviewed by the GP. We saw examples of how the principles of STOMP (stopping over medication of people with a learning disability and autistic people is a national NHS England work programme to stop the inappropriate prescribing of psychotropic medicine medications) were followed. These principles were being met. We saw examples of reviews and reduction in psychotropic medicines for people.