Lancaster Court

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 changed to 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 legal regulation in relation to medicines management, staff competency and risk assessments.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The registered manager had not always identified sufficient actions/learning following incidents. For example, a person was injured when staff were supporting them to transfer from their bed to a chair by hoist. Staff had been trained in moving and handling, but not had a competency assessment as the process was for this to be done after six months. Following the incident they were re-trained but there were no plans to assess competency for a further 6 months The registered manager reminded staff to check the condition and positioning of the sling, but this had not been an issue during the incident; the issue was staff not monitoring the person to prevent them hitting their head and this was not noted in the actions/learning. Therefore, we were not assured this would not happen again.

Staff were made aware of incidents and able to give recent examples. They told us they read care notes and information was shared at staff handover meetings. A staff member told us, “If any safeguarding or any other issues occurred then all staff will be informed through reading and signing the document. Also has regular staff meetings and staff will be reminded anything important. Same with incidents or any complaints.”

People’s relatives were informed when incidents occurred. A relative told us, “[Person] had a seizure, and they told me straight away.”

People’s records showed the service worked with other professionals. They gave mostly positive feedback about working with the home. A professional said, “Considering the difficulties within the NHS finding staff and beds for discharge in the community Lancaster Court has coped remarkably well.”

We saw referrals were made to other services as required such as speech and language therapists. A person told us, “The optician checked my eyes, I have near and distance glasses. The speech therapist came.”

The registered manager had a tracker to monitor safeguarding referrals. This included a very brief summary of what happened. The registered manager told us there were none open at the time of our visit.

Staff had received training in safeguarding and understood their responsibilities. They told us they would report any concerns to their manager. A staff member said, “It is protecting our residents from harm or abuse…could be sexual, physical, money.”

Some people had stair gates across their doorways. We were told this was to prevent other residents from entering their rooms. We reviewed the Deprivation of Liberty Safeguard applications and found they included blanket statements related to locked doors and keypad entry to the home, but they did not include the use of gates, which is restrictive practice. We fed this back to the registered manager, and they told us following support from GP and mental health input for the people accessing other people’s bedrooms this behaviour had reduced, and they were taking the gates away.

The registered manager had not ensured there were assessments for all risks to people. For example, a person with diabetes did not have a diabetes risk assessment. However, there was some guidance in their care plan for staff and the risk assessment was completed following our visit. Another person had increased risk of falls following PRN medicines, which caused dizziness, but this was only noted in their emotional care plan; there was no medicines risk assessment, and it was not in their mobility or falls risk assessments. Following our visit, the falls risk assessment was amended to reflect this.

People’s weights were monitored, and staff completed food and fluid charts where required. However, we reviewed a person’s care plan which stated they were to be offered milkshakes daily due to weight loss and saw no evidence of this in their records. Staff we spoke with appeared to know people well. They gave examples of how they supported people with behavioural support needs. However, no one had behaviour monitoring charts to support understanding of triggers and how to de-escalate incidents.

The home was spacious and well-maintained. However, it lacked measures to support people to find their way around the home. We saw decoration and improvements were planned for some of the dining areas. The registered manager completed monthly health and safety audits, we saw issues were identified and added to their service improvement plan. However, actions were not always followed up. For example, it noted an issue with open food not labelled in the fridge and we found this was still the case during our visit. At our second visit we noted 2 occasions where staff had the vacuum cleaner trailing across the corridor and across a bedroom doorway. We fed this back to the managers who would address this with staff.

The service did not always have enough staff to meet people’s needs. During both our visits, we found staff were not visible in communal areas. Some people were cared for in bed and three people told us they were bored and lonely. Staff tended to be task-focused and there was a lack of time for sufficient social interaction with people.

We received mixed feedback from staff and people about staffing levels. Staff told us of people who were not on 1-1 care but tended to require 1 staff to support them, leaving the rest of the floor short staffed. We were told of occasions when people were supported with personal care by night staff very early in the morning and saw evidence of this in people’s daily logs.

Following our visit, the registered manager told us they had added a staff member for 1 floor, staff confirmed this telling us, “Recently we have been given an extra carer during the day shift which helps a great deal. We are now spending quality time with our residents, and it's given the care team leaders more time to spend on care plans and assessments and reviews.”

The registered manager had not ensured staff were competent in moving and handling. Whilst training was completed, the procedure was for competency assessments to be completed after 6 months. There had been some injuries prior to the inspection to people during moving and handling and whilst staff were re-trained following these, we were not assured it was effective without including an assessment of competency soon after.

The home was visibly clean.

The service had an infection control policy (IPC) which was in date and included guidance for management of covid. Staff completed IPC audits. We saw issues were identified and action taken.

The team meeting minutes included a reminder for staff to support people to wash their hands before meals and we observed staff doing this during our visit.

The registered manager had not ensured there were always protocols to guide staff for when to administer PRN medicines. PRN medicines are those administered as and when required. Where protocols were completed, they were not personalised. This meant there was not clear guidance for when staff should administer the medicines and in 1 record we reviewed, we found it was being administered regularly at 8.30am. There was a risk staff were administering the medicine in anticipation of the behaviour. Some PRN medicines had regular times recorded on the Medicine Administration Chart (MAR). Following our visit, the registered manager told us all PRN protocols had been completed in a personalised way and all regular times had been removed.

A person had their medicines administered covertly. There was a mental capacity assessment for this and guidance for staff to crush and disguise the medicines as agreed with the GP and pharmacist. We noted a medicine which stated it was not to be crushed. The registered manager told us this was a capsule administered before all others in the morning and the person was compliant with it. However, there was nothing in the person’s medicines care plan about this.