Lee Valley Care Services Limited

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 remained 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 service was in breach of legal regulation in relation to safe care and treatment. This was because people’s care plans and risk assessments did not always consistently provide the level of detail required to support people safely. Medicines were not always managed safety. The provider also did not have effective arrangements to manage risks associated with infection prevention and control.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Managers listened to concerns about safety and investigated and reported safety events. Lessons were learnt to identify and embed good practice.

Safety incidents were appropriately investigated by the management team. Where risks were identified, these were documented, and the service worked with people to improve their safety, for example by considering what support they would need in place when accessing the community.

There was a culture of learning from safety events. We saw evidence the registered manager analysed incidents, accidents and safeguarding concerns and that the lessons learned were shared with staff at team meetings.

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.

The registered manager completed pre-admission assessments with people prior to them moving into the service. Information was gathered to ensure the service could meet people’s needs and provide appropriate support such as communication, diet and nutrition, activities and health care needs. This information was recorded and shared with staff through each person’s care plan.

People were supported to access healthcare services when required, and systems were in place to ensure essential information was shared in the event of an emergency. For example, hospital passports were readily available to staff if a person needed to attend the hospital.

A healthcare professional told us, “The staff effectively supported the recent move of an individual from the home to [Lee Valley Care Services] and were responsive to requests for information.”

The provider worked with staff, people and healthcare partners to understand what being safe meant to them and the best way to achieve that.

Staff were able to tell us about the different types of abuse and could describe what they would do to protect people if they had concerns. Training records showed that all staff members had completed safeguarding training.

The service had safeguarding systems and processes in place to protect people from abuse. The registered manager described efforts to develop a positive and open safeguarding culture, where staff felt confident to share concerns. This included regular staff meetings where staff were reminded that, “If they are ever unsure, they should always ask or escalate rather than assume someone else has already reported a concern.”

The registered manager was aware of their responsibility to notify the Care Quality Commission and the local authority of any allegations or incidents of abuse.

The provider did not work well with people to understand and manage risks. They did not have effective arrangements to appropriately identify risks and to develop comprehensive management plans to help mitigate identified risks.

People’s individual risk assessments were overall completed. However, these did not always consistently provide the level of detail required to identify known risks and to mitigate them and support people in a safe way.

Risk assessments and care plans were generic and lacked sufficient guidance for example regarding a person’s specific behavioural support needs. Staff reported that a person could express agitation and restlessness and could break objects as a result. However, there was no risk assessment in place for this specific risk and the care plan failed to guide staff on how to respond safely. Whilst another a person’s care plan stated that district nurses performed catheter changes, this was not captured in the care plan and there was no catheter care protocol or continence risk assessment in place. This meant that staff did not have all the necessary information around supporting the person with their continence care needs and actions to take to mitigate the risk of infection.

The shortfalls that we identified at this inspection are very similar to the ones we identified at our last inspection in June 2023. This meant that the provider had not taken enough action to identify and manage risks to people and to provide safe care to them.

People had a personal emergency evacuation plan (PEEP) in place, which took into account the person's comprehension and ability to take appropriate action in the event of a fire.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, and facilities supported the delivery of safe care.

Cupboards in the kitchen were generally dirty and there was a distinct lack of kitchen equipment such as cutlery and crockery. Items were stored inappropriately such as PPE (personal protective equipment) being stored with a packed box of crisps in one cupboard which also had central heating pipes in. The vent in the kitchen was dusty and greasy and the toilet on the first floor opposite the office was dirty and had stains on the floor. This meant that people were not being appropriately protected against risks that can arise if the environment is not maintained to a high standard of cleanliness

Another toilet near the kitchen was deemed out of use however there was no notice on the door, and it was being used for storing items for example a zimmer frame, a stool, a bedpan and a washing up bowl There was worn furniture in the living room and some areas of the building was in need of decoration. This did not ensure that people were living in well decorated and maintained environment.

All environmental checks in the home had been carried out including fire safety checks however, we saw two fire doors wedged open on the day of the assessment.

We discussed the above with the registered manager and they immediately implemented a Renovation Improvement Plan to address the identified issues.

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.

There were sufficient numbers of staff employed who were knowledgeable and passionate about the people they supported. Appropriate recruitment processes were followed to ensure staff were suitable persons to support people, including use of Disclosure and Barring Service (DBS) checks which cross reference against police records. A DBS check is a criminal record check used by employers to help them make safer staffing decisions.

Records confirmed there was a stable team who had regular supervision and up to date training. Meeting minutes confirmed the registered manager held monthly staff meetings and ensured daily handovers were in place, which reinforced professional standards and decision‑making responsibilities.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading. We were not assured that the home had robust infection control processes in place.

On the morning of the assessment all bathrooms and toilets in the building had no liquid soap or paper towels for handwashing. We were informed that these were replenished every Monday, however in the meantime people could not wash their hands after using facilities in the home. The registered manager rectified this a few hours later after we pointed it out, but their own systems had not identified these shortfalls.

Although staff cleaned the service daily and we saw records of this, we observed many areas of the home needed a deep clean. The cupboard where the cleaning materials were kept, was dirty, and most of the cleaning products had expired, which meant their effectiveness might have been reduced and these should not have been in use. As a result, people were not being adequately protected from the risk of the spread of infections.

Staff confirmed they had enough Personal Protective Equipment (PPE) available for their use.

The provider did not make sure that medicines and treatments were safe and met people’s needs.

Some protocols for administering medicines to be administered when required (PRN) and people’s medicine administration record sheets (MAR) were missing or were sometimes inaccurate.

There were discrepancies regarding one person’s medicines. Both the MAR and the medicine label on the box instructed the medicines to be administered daily. However, the staff said it was a PRN medicine and had therefore omitted daily administration. After the inspector pointed this out, staff contacted the GP who confirmed the medicine was stopped in April 2026. This meant that staff had not made arrangements for the MAR to be updated and to dispose of the medicine if it was not needed, so the person was protected from the risk of receiving a medicine that they did not require

For one person, their MAR stated no known allergies but the care plan and profile page on the electronic care planning system stated the person had a known allergy to a certain type of medication. As staff rely on the MAR when administering medicines, this discrepancy posed a risk of an inappropriate or unsafe medicine being administered.

We found that insulin (a medicine to help control blood sugar levels for people who are diabetic) administration by injection and blood sugar monitoring were being carried out by care staff without appropriate arrangements and safeguards in place to ensure the safety of people. Insulin injection and blood sugar monitoring are activities that are generally carried out by trained nurses. Where an activity that needs to be performed by a nurse is delegated to a care worker, specific safeguards need to be in place in terms of accountability, monitoring and safety.

There should also be clear processes to train, observe and assess competencies of the care workers carrying out the delegated tasks. We did not see that the necessary arrangements and safeguards were in place. These shortfalls meant that people were not always being appropriately protected from the risk of avoidable harm.