Lombard House

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

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.

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 meant patients were not safe and were at risk of avoidable harm. Emergency equipment and medicines were found out of date or not properly checked, and some prescription creams were unlabelled or no longer prescribed. The provider has since replaced or disposed of items, updated the emergency bag, labelled creams, informed staff, and plans to audit medicines as a known risk area.

However, all wards were clean, well equipped, well furnished, well maintained and fit for purpose. Staff assessed and managed risks to patients and themselves well. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service managed patient safety incidents well.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

We have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

From November 2024 to October 2025 there were no serious incidents reported. There were 117 incidents in total. There were 18 relating to verbal aggression, 37 to physical health and 47 incidents were categorised as other incidents. Leaders described how people in the service had increasing physical health care needs, but the service had good support from the local GP surgery.

The service developed a lessons learnt bulletin each month. The bulletin was shared with all staff. We saw evidence that changes had been made because of feedback. Staff explained that after a patient became unwell and required hospital care, they reflected on the incident and agreed to carry out more proactive checks in future. They also noted the importance of monitoring subtle changes in routine, as the patient had not reported feeling unwell until they were very unwell. All staff knew what incidents to report and how to report them.

We work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when people move between different services.

We scored the service as 3. The evidence showed a good standard. The service 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.

The service’s referral and admission processes ensured that all essential information about the patient was received to ensure the patient’s needs could safely be met. New referrals to the service were assessed initially by the hospital director and multidisciplinary team. The ward nurse and doctor would then conduct a face-to-face assessment. There were no vacancies on the ward and no patient waiting list. The service received referrals nationally but primarily accepted for those locally to support continuity of care.

Discharge planning started at the point of admission; the people and carers were fully involved in discussions about discharge and next steps. Patients told us they were involved in their discharge planning. All 3 of the carers we spoke to were aware of discharge planning for their loved ones.

Within the service there were 3 people clinically ready for discharge and 3 people were part way through their transition into the community. The service described how they had well-supported transition plans and weekly meetings with providers of new placements where people were moving to. Managers described challenges with moving people on, due to the complexity of needs of patients, and the scarcity of suitable community homes.

We work with people to understand what being safe means to them as well as with our partners on the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and we make sure we share concerns quickly and appropriately.

3. We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They 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 service shared concerns quickly and appropriately.

Staff had safeguarding training, knew how to make a safeguarding alert, and did so when appropriate. Overall, 100% of staff had received safeguarding level 3, level 4 and e-learning. Staff had access to safeguarding leads within the service. The service gives all visitors a safeguarding card and contact details for visitors to report any safeguarding concerns they have. There was a good practice guide to responding to a safeguarding concern. This was to aid staff’s understanding. There was clear local guidance for staff on the process for staff to follow if there were safeguarding concerns.

Safeguarding quality assurance meetings took place monthly. This was led by the safeguarding lead to discuss any incidents and learning from them.

Staff gave examples of how to protect people from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies.

The lounge displayed easy read safeguarding posters in picture format.

Mental Capacity Act

94% of staff had had training in the Mental Capacity Act.

Staff had a good understanding of the Mental Capacity Act, in particular the 5 statutory principles.

The provider had a policy on the Mental Capacity Act, including deprivation of liberty safeguards. Staff were aware of the policy and had access to it.

Staff knew where to get advice from within the provider regarding the Mental Capacity Act and took all practical steps to enable patients to make their own decisions.

We work with people to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enables them to do the things that matter to them.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff used restraint and seclusion only after attempts at de-escalation had failed. The ward staff participated in the provider’s restrictive interventions reduction programme. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We reviewed 4 risk assessments and risk management plans during the assessment. Plans were developed with involvement from the multidisciplinary team to ensure they were easy read and understandable. People had been offered a copy of their safety plan and plans were regularly updated. Patients told us they talk about their risks at multidisciplinary meetings.

Staff communicated with patients to ensure they understood their care and treatment, including using effective methods to support those with communication difficulties.

Staff enabled patients to give feedback on the service they received, there were regular community meetings and minutes in a pictorial format were available for patients to read in the lounge.

Staff ensured that people could access advocacy. The lounge displayed an easy read poster showing how patients could access an independent mental health advocate.

We detect and control potential risks in the care environment and make sure that the equipment, facilities and technology support the delivery of safe care.

We scored the service as 1. The evidence showed significant shortfalls. The service 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.

We observed out of date equipment in the emergency bag, equipment was not always recorded as checked. One blood pressure machine was showing an old sticker and an in date sticker, making it difficult to confirm that it had been calibrated, however the provider evidenced that all 5 blood pressure machines had been calibrated.

Emergency medicines had been identified as out of date and new items had been received but the bag had not been updated. The provider has now replaced the medication, and the bag has been sealed by the pharmacist.

There was a step in the hallway near the kitchen that patients had to navigate. A temporary ramp was installed for a patient who used a walking frame. We viewed the patient using the ramp during our visit and raised safety concerns. Leaders told us that the step before the kitchen entrance had been on the risk register for several years waiting to be made into a level access. This created risk for patients.

Staff carried out regular risk assessments of the care environment and there was CCTV in the communal areas. A ligature heat map and ligature cutters were observed in the nursing office. Staff attend annual face to face ligature training. In November 2025, the provider carried out a pre ligature audit risk assessment.

Bedrooms and bathrooms had patient alarms and 1 patient who had additional physical health care needs wore a wrist alarm.

Yellow stickers were visible on steps to alert patients and visitors to trip hazards. While we were on site there were maintenance works being carried out in the garden. Leaders told us that all patients were accompanied in the grounds.

Since our last assessment, an additional bathroom had been installed so patients now had a choice of 3 wet rooms on the ground and first floor.

We make sure there are enough qualified, skilled and experienced people, who receive effective support, supervision and development and work together effectively to provide safe care that meets people’s individual needs.

We scored the service as 3. The evidence showed a good standard. The service 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.

At the time of assessment the service had 2.4 full time equivalent registered nurse vacancies and 1 speech and language therapist vacancy. Nursing shifts were covered with regular bank staff, who patients knew. The speech and language vacancy was covered by using the specialist from a neighbouring hospital and locum staff.

The average turnover and sickness absence from October 2024 to September 2025 was low, 1.8% for staff turnover and 1.6% for staff sickness absence.

Patients and carers told us they went out regularly with staff and only occasionally staff were not available to provide escorted leave. There were adequate staff to carry out and record observations of patients and physical restraint, although restraint was rare.

Staff had received and were up to date with mandatory training. The training was appropriate for the patient group using the service. The overall mandatory training compliance was 94.5%. All staff had completed the Tier 1 Oliver McGowan training on Learning Disability and Autism (for a general awareness of the needs of autistic people and people with a learning disability) and 37% of staff had completed the Tier 2 training (for staff who provide direct care of autistic people and people with a learning disability) the remaining staff who had not completed tier 2 training had been booked onto an upcoming course.

We assess and manage the risk of infection, detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.

3. We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff maintained equipment well and kept it clean. All ward areas were clean, had good furnishings and were well-maintained.

Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly.

Staff adhered to infection control principles, including handwashing. Overall, 100% of staff had completed the providers infection prevention control training.

Patients and carers told us the service was clean. Patients helped to keep the service clean, and we saw a patient cleaning rota, this enabled patients to maintain or develop independent living skills.

We make sure that medicines and treatments are safe and meet people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happen.

3. We scored the service as 3. The service ensured that medicines and treatments were safe and met people’s needs, capacities, and preferences. They always involved people in planning.

We reviewed 5 prescription charts during our on-site assessment.

Staff followed good practice in medicines management, dispensing, administration, medicines reconciliation, disposal and did so in line with national guidance.

The service administered medicines in line with Stopping Over-medication of People with a learning disability, autism, or both (STOMP).

The service had an external pharmacy attend on a fortnightly basis to carry out medicines management audits and feed back to staff with any issues raised.

However, opened, unlabelled tubes of skin and fungal cream were found in the fridge. The provider has since labelled all creams with the patient’s name and expiry date, disposed of those no longer prescribed, and alerted staff to the learning.