Lyndon Croft

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 requires improvement.

At this assessment the rating has changed to good.

This meant people were safe and protected from avoidable harm.

The provider was previously in breach of the legal regulations in relation to safe care and treatment. Improvements were found at this assessment, and the provider was no longer in breach of these regulations.
 

This service scored 75 (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.

People experienced care within a positive learning culture where staff reported, reviewed and learned from incidents, accidents and concerns to help improve outcomes and promote safer care. staff told us leaders encouraged openness and honesty, and they felt supported to raise concerns, discuss issues and reflect on practice without fear of blame. One staff member told us, “If I need support or guidance I go straight to the seniors or managers, they are always happy to support me or provide guidance”.

Managers reviewed incidents and safeguarding concerns, carried out investigations where required and used analysis to identify trends, themes and opportunities for improvement. They shared learning with staff and across the wider organisation to help prevent similar incidents from occurring and to promote consistent practice.

Leaders had introduced designated fire zones following learning from an incident within the wider organisation. This enabled staff to identify the location of a fire more quickly and respond appropriately, demonstrating a positive learning culture and a commitment to improving safety.

Since the previous assessment, the provider had strengthened oversight, reporting arrangements and quality assurance processes. These improvements supported a more proactive approach to risk management, embedded learning from events and started to drive improvements in the quality and safety of people's care.
 

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.

People experienced coordinated and well-planned care because managers implemented systems to support safe admissions, transfers and ongoing care. Before people moved into the service, staff completed comprehensive assessments involving the person, those important to them, healthcare professionals and senior staff. These assessments helped managers determine whether the service could safely meet the person's needs while also considering the wellbeing and compatibility of people already living in the home. One relative told us “Provider came and did an assessment at home with me and my loved one and went through everything. They took a lot of notes about medication; preferences; hobbies; diet etc and we were left feeling they were really interested in[person].”

Staff developed care plans and risk assessments following admission and updated them as they got to know people better and as needs changed. Leaders reviewed care plans following significant events, such as falls, accidents, hospital admissions or changes in health, to ensure staff had access to current information and guidance. Staff shared key information through daily handovers and discussions, helping to promote continuity, consistency and safe care delivery.

People received timely support to access external healthcare services when required. Staff worked in partnership with healthcare professionals and made referrals when people's needs changed. When people transferred to hospital or other services, staff provided relevant information about their health conditions, medicines, care needs and treatment preferences. This helped ensure professionals had the information they needed to support people safely and maintain continuity of care across services.
 

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.

Safeguarding practice had improved since the last inspection. The provider had strengthened oversight, staff knowledge and reporting processes, helping to create a safer environment for people and ensuring concerns were identified, managed and escalated appropriately. One person told us, “I’m safe; I think I’m safe because nothing has happened to make me feel scared or unsafe”.

People were supported by staff who understood their responsibilities to protect them from abuse and avoidable harm. Staff had completed safeguarding training and demonstrated a good understanding of the different types of abuse, the signs to look for and the actions they would take if they had concerns about a person's safety or wellbeing.

Staff were aware of the provider's whistleblowing procedures and knew how to access the organisation's whistleblowing contact number. Information about whistleblowing was displayed throughout the service to promote awareness and encourage staff to speak up.

Leaders responded appropriately to safeguarding concerns and made referrals to the local authority and CQC when required. Records showed safeguarding concerns were logged, investigated and reviewed, with outcomes documented and actions taken to reduce the risk of recurrence.

Overall, we found the provider had made significant progress in strengthening safeguarding arrangements since the last inspection. Staff demonstrated improved knowledge and confidence, concerns were appropriately escalated and reviewed, and leaders had implemented more robust systems to promote learning, accountability and safer outcomes for people.
 

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.

The provider had made significant improvements since the previous inspection in relation to risk management, the quality of risk assessments and the involvement of people and professionals in managing risks. Systems and processes were more robust and supported a more person-centred approach to assessing, reviewing and managing risks.
People were supported through risk assessments that identified known risks and generally provided clear guidance for staff on how to manage these safely whilst promoting people's independence, choice and wellbeing. One person told us “The reason that I came here is that I fell in my home and was in hospital for a while. I was discharged from hospital to this care home. I am safe here and I haven’t fallen since coming here. I have a walker now which helps me a lot”.

Staff demonstrated a good understanding of people's individual risks and were able to explain how they monitored and responded to these in practice.

Risk assessments and behaviour support plans were generally detailed and reflected people's needs, preferences and circumstances. Records demonstrated that people, their relatives and relevant professionals were involved in assessing and reviewing risks where appropriate. Where people lacked capacity to make specific decisions, staff completed Mental Capacity Act assessments and best-interest decision-making processes to support the least restrictive and most appropriate approach to risk management.

Staff monitored people's risks regularly and reviewed care plans and risk assessments in response to changes in need, accidents, incidents or professional advice. Records evidenced healthcare professionals were involved when required and their recommendations were reflected within care documentation and daily practice.

Staff demonstrated a clear understanding of people's dietary needs and how to support them safely. The cook was knowledgeable about individual dietary requirements and explained how meals were prepared and served in line with people's assessed needs. Staff had completed training in the International Dysphagia Diet Standardisation Initiative (IDDSI), and safe dietary practices were embedded within the service. This represented a significant improvement since the previous inspection, with staff demonstrating increased knowledge, confidence and understanding of modified diets and the importance of ensuring people received food and drink prepared in accordance with their assessed needs.

Managers demonstrated a responsive approach when opportunities for improvement were identified. For example, when additional detail was required within a risk assessment, and where a risk assessment relating to anticoagulant medicines was not in place, managers took immediate action to review and update the relevant documentation. Anticoagulant medicines increase the risk of bleeding and therefore require appropriate risk assessment and monitoring to support people's safety.

Most risk assessments provided staff with the guidance they needed to support people safely. However, one person living with sight loss did not have specific guidance in place to help staff understand and manage risks associated with their visual impairment. The provider addressed this during the inspection.

People with specific health conditions received care informed by detailed risk assessments and support plans. For example, staff had access to comprehensive guidance for supporting a person living with diabetes, including symptoms to monitor, potential risks and the actions required to support the person safely.

People were supported to take positive risks and maintain their independence. Staff balanced safety with people's rights, preferences and choices, enabling people to access activities, maintain relationships and participate in their daily lives whilst reducing the risk of avoidable harm.
 

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

The provider had made significant improvements to the environment and premises since the previous inspection. People lived in a well-maintained, clean and comfortable home that supported their safety, wellbeing and independence. One person told us “Every day my room is cleaned, they clean the floor and dust. The cleaner is very nice”. A Relative shared “The home has a nice ambience; its clean and doesn’t appear clinical”.

Leaders ensured all required servicing and compliance checks were completed and remained up to date, including gas safety, electrical safety and legionella testing. The provider maintained effective oversight of health and safety obligations to help ensure the environment remained safe for people, staff and visitors.

The home had benefited from ongoing refurbishment and redecoration, creating a welcoming and pleasant environment for people. Further improvements were underway, demonstrating the provider's commitment to continuously enhancing the living environment.

Staff reported maintenance concerns promptly and the provider had effective systems in place to record, monitor and complete repairs. Records showed equipment checks, servicing and maintenance were undertaken regularly to ensure equipment remained safe and fit for purpose.

The provider had strengthened environmental safety arrangements since the previous inspection. COSHH documentation had been reviewed and updated and included products used by both the external cleaning contractor and the provider's suppliers, helping to ensure hazardous substances were managed safely.

The provider had made significant improvements to fire safety arrangements since the previous inspection. People benefited from living in an environment where leaders had strengthened systems and processes to help protect them in the event of an emergency.

A current fire risk assessment was in place, and the fire alarm system was fully operational at the time of our inspection. Records demonstrated regular checks and monitoring were completed to ensure fire safety equipment remained effective.

Staff completed fire safety training and participated in regular fire drills during both day and night shifts. This helped ensure staff understood how to respond appropriately in an emergency and could evacuate people safely.

Personal Emergency Evacuation Plans (PEEPs) were in place and provided staff with clear guidance on how to support people to evacuate safely. Emergency grab bags were fully stocked, readily available and contained information required to support people during an evacuation.

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.

People were supported by enough suitably skilled, competent and experienced staff. People received care from staff who knew them well and understood their individual needs, preferences and routines. Relatives told us the staff team were positive and described staff as caring, knowledgeable and responsive to people's needs.

The provider had strengthened staffing arrangements since the previous inspection and maintained oversight of recruitment, staffing, competency and training. Safe recruitment processes were in place and supported by the provider's human resources team, with appropriate pre-employment checks completed before staff commenced work. Recruitment information was also available for external cleaning staff working within the service.

Managers had recently strengthened the staff team through the recruitment of experienced senior staff who were supporting the service's continued development and improvement. New staff had completed a comprehensive induction programme which included shadowing experienced colleagues, observations of practice and competency assessments to ensure they could carry out their roles safely and effectively.

The provider maintained robust oversight of training compliance through central monitoring systems and regular review of mandatory training completion. Training compliance exceeded the provider's target, and staff had completed training relevant to their roles and responsibilities. Staff demonstrated a good understanding of safe working practices and applied their learning in daily practice. Competency assessments were completed in key areas, including medicines management, to ensure staff maintained the knowledge and skills required to support people safely.
Staff received regular supervision and support to discuss their performance, training, wellbeing and development needs. Leaders monitored staff performance and took appropriate action where improvements were required, demonstrating effective oversight and accountability.

The service used permanent and bank staff to cover where necessary to provide consistency for people and reduce disruption to their care. Staffing levels were determined using a dependency tool and reviewed in response to people's changing needs, helping to ensure sufficient staff were available to provide safe and effective support.

Staff described effective communication systems, including daily huddles, handovers, team meetings and staff noticeboards, which helped ensure important information was shared and people received consistent care. Most staff told us managers were approachable, visible within the service and promoted an open culture where they felt supported and able to contribute ideas for improvement.
 

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.
People lived in a clean, tidy and well-maintained environment. Throughout the inspection, we found the home was visibly clean and staff followed infection prevention and control (IPC) procedures designed to reduce the risk of infection and cross-contamination.

Staff demonstrated a good understanding of IPC principles and applied these consistently in practice. We observed staff carrying out effective hand hygiene and using personal protective equipment (PPE) appropriately and in line with current guidance. PPE stations were well stocked, and equipment was readily available throughout the home to enable staff to follow safe practices.

The provider had maintained equipment in a clean, safe and serviceable condition to support effective infection prevention and control. Staff stored equipment appropriately to reduce the risk of cross-contamination and carried out regular checks to ensure equipment remained fit for purpose. The provider used an external cleaning contractor and maintained oversight of environmental cleanliness through routine cleaning schedules and management checks. Records evidenced cleaning tasks were completed, monitored and reviewed, providing assurance that high standards of cleanliness were maintained throughout the service.

Management demonstrated a clear understanding of the procedures required when managing infectious illnesses, including isolation and outbreak arrangements. Staff were knowledgeable about these processes and described how they would implement them to protect people, visitors and colleagues.

Information and signage were displayed throughout the service to support visitors in following infection prevention and control measures and promote safe visiting arrangements.
The provider had made improvements to laundry processes following previous concerns relating management of contaminated laundry. Staff had received additional training and we observed improved practice, including the correct use of red laundry bags for contaminated items. Bed linen and towels were provided and laundered through an external contractor, further supporting effective infection control arrangements.

The service had recently experienced a reduction in its food hygiene rating. Leaders responded promptly to the findings and implemented actions to address the areas identified for improvement. This included providing additional infection prevention and control training and reinforcing expectations around safe food hygiene and hand hygiene practices. Management demonstrated oversight of the actions taken and a commitment to improving standards and maintaining a safe environment for people who used the service.

The provider continued to monitor infection prevention and control arrangements through regular audits and oversight. A recent external IPC audit achieved an initial compliance score of 98%, providing assurance that effective systems and processes were in place to protect people from the risk of infection.

Overall, the provider had made improvements since the previous inspection and demonstrated effective infection prevention and control practices. Systems were embedded; staff understood their responsibilities and managers-maintained oversight of the cleanliness, safety and hygiene of the environment.
 

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.
The provider had made significant improvements to medicines management since the previous inspection. Leaders had strengthened medicines systems, increased oversight and implemented improvements to support the safe administration, recording and monitoring of medicines.

Staff managed medicines safely and demonstrated a good understanding of their responsibilities. Improvements had been made to the management of medicines due when people were asleep. Staff were able to explain the required checks, escalation procedures and actions to take where medicines could not be administered as prescribed. Records provided assurance these processes were being followed consistently.

Staff worked proactively with healthcare professionals to support people's medicines needs. Weekly GP ward rounds took place and staff sought timely advice and guidance when concerns arose or people's needs changed.

Leaders completed regular medicines audits to monitor practice and identify opportunities for improvement. These systems provided greater oversight of medicines management and had contributed to improvements since the previous inspection. The provider had also strengthened management capacity, and additional oversight was supporting continued improvements in medicines governance and recording.

Despite these improvements, we identified some areas where documentation could be strengthened further to ensure records were consistently detailed and provided staff with clear guidance.
Records relating to covert medicines demonstrated that best-interest decision-making processes had taken place where required. However, documentation did not always clearly identify all individuals involved in the decision-making process, including family members and their relationship to the person. In addition, records did not consistently evidence GP involvement within all associated documentation, although supporting records were available elsewhere. Information regarding the agreed method of covert administration and evidence of pharmaceutical advice was not consistently reflected across all related records. Managers acknowledged these areas could be strengthened to improve consistency and accessibility of information.

Some PRN (as required) medicines protocols required additional person-centred detail. For example, one protocol relating to morphine sulphate did not clearly describe how the person may present when experiencing pain or reference the pain assessment tool used by staff to support decision-making. Similarly, one protocol for lorazepam did not contain sufficient detail about the signs of anxiety or distress the person may display, or the alternative strategies staff should consider before administering the medicine. Although this information was available elsewhere within the person's care records, it had not been incorporated into the medicines protocols to support consistent decision-making.

We also identified one person prescribed anticoagulant medicine who did not have a corresponding anticoagulant care plan or risk assessment. While relevant risk information was recorded within the electronic medicines administration system, (MARS) guidance was not held consistently within associated care records. Managers responded immediately to this feedback, implemented an anticoagulant care plan for the person concerned and reviewed records for all people prescribed anticoagulant medicines to ensure appropriate assessments and care plans were in place.