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Archived: Lammas Lodge

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All reports

Inspection report

Date of Inspection: 21 June 2011
Date of Publication: 8 August 2011
Inspection Report published 8 August 2011 PDF

People should be protected from abuse and staff should respect their human rights (outcome 7)

Not met this standard

We checked that people who use this service

  • Are protected from abuse, or the risk of abuse, and their human rights are respected and upheld.

How this check was done

Our judgement

Failings in the management of the home had put everyone in the home at risk of abuse and several had experienced poor outcomes.

User experience

Some people had been hit or verbally abused by another person they were living with quite frequently. Many of these incidents had not been reported to the victims’ funding authorities. This had meant that people’s representatives had not been fully informed and so could not assess whether the home was meeting their needs and keeping them safe.

Following our visit social care professionals observed one person in the home behaving cautiously around another. It was judged that this was because they were frightened of the other person. This was not an acceptable situation as it would be having a detrimental effect on the person’s wellbeing.

Other evidence

The company has a procedure for staff and home managers to follow when serious incidents take place in one of their care homes. This is so they can monitor the service being provided and ensure the right action is taken. Following our visit to the home senior staff in the company found over sixty incident reports that had not been shared with senior managers or put into the company’s monitoring system. Some of these dated back to August 2010.

The manager had raised a safeguarding alert in April following an incident between two people living in the home. This incident between two people who live at the home was minor compared to others that came to light after our visit. During our visit we asked the manager if there had been any other safeguarding concerns and he said this was the only one. It is not clear why the manager raised an alert on this one occasion and not about other more serious incidents.

We spoke to several staff during and in the days following our visit. They had been provided with safeguarding training and were aware of the company’s whistle-blowing policy. Several staff had been concerned about the situation in the home over the previous four months in terms of staffing levels and how behaviours and incidents of physical aggression were being managed. Several factors including a lack of confidence about how senior staff in the company would react had led to none of them speaking out.

One of the two senior managers responsible for overseeing the home visited at least monthly. Their presence and monitoring role should have led to the staff concerns being identified. Staff told us they were not asked by these managers to speak in private so they did not feel able to tell them about the problems.

The manager told us that someone had recently made an anonymous complaint to the company that the police had been called to the home because of incidents of behaviour. He said this was investigated by the company and found to be untrue. The enquiries that were carried out by the company had failed to identify the problems at the home.

The monitoring of people’s behaviours and planning how to meet them was the joint responsibility of the manager, a behaviour therapist and consultant psychiatrist. The therapist and psychiatrist who were both employed by the company held monthly behaviour management review meetings at the home. Staff told us that these professionals did not spend time observing the people in the home and how the staff were supporting them but focused on analysing incident reports. Staff felt that they did not understand about how difficult situations really were to manage and the guidance they issued was not effective. These visiting professionals had not raised any concerns within the company or though safeguarding channels about the level and frequency of incidents occurring in the home in recent months.

Following our visit we raised a safeguarding alert about the welfare of everyone in the home. This led to local multi-agency safeguarding meetings being held and the situation being investigated by other agencies and the company. The company cooperated fully with this process and took prompt action to help protect people.