Lindau Residential Home

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• 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 people’s safe care and treatment and the way people’s medicines were managed.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Lessons were learnt to continually identify and embed good practice. The registered manager completed a monthly review of the service which included learning points. Analysis had been carried out by the management team to determine the root cause of incidents and actions were taken to prevent things happening again. For example, the management team had learnt from an incident where a relative was wanting to making a decision about their loved one’s health and welfare, believing they had lasting power of attorney (LPA) to make this decision. When records were reviewed it was found the relative only had lasting power of attorney to make decisions about their loved one’s property and finances. So that the service had a better understanding of who had legal powers to make decisions on behalf of people, they had reviewed every person’s care records. This was to establish if families had LPA’s for health and welfare, property and finance or both. Another lesson learned was to only accept medicines changes from the GP practice in writing. This was because a GP had arranged a dose increase for a person’s medicine that had already been stopped by another GP. A staff member said, “The management team reviews lessons learned from incidents, they have an action plan, they do say stuff about it in meetings and handovers.”

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 provider had an electronic care planning system. This enabled the staff team to create hospital passports when these were needed. A hospital passport helps people to give hospital staff and other services important information about them and their health when they go to hospital.

The provider had taken on some people at the service with short notice following a fire which had closed a care home. Despite being emergency placements, these people were assessed to check that the service was able to meet their needs before a placement was offered.

People were supported to maintain their health, attend appointments both inside and outside of the service. Where routine health checks were undertaken people had support from people who they know well to understand what was happening. A person told us, “The staff would call a doctor if I was unwell.”

The service had maintained regular contact with local authority social workers. This included ongoing work with the GP and other health and social care professionals. Staff told us they were able to contact the GP. We observed community nursing staff visiting the service to provide routine nursing care such as wound management. The home visiting team from the GP surgery also visited because the staff had alerted them to someone with a cough. A staff member told us, “We monitor food, fluid and weights and let the GP know about any concerns.”

A relative said, “Staff always let me know what is going on and explain things to me. [Person] had a blood test last week, and the staff will let me know the result.” Another relative told us, “They tell us things they do, such as referrals to the GP. We trust them.”

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. People were safe and were protected from harm. Safeguarding policies included information about safeguarding children from abuse. This is because staff in care services come into contact with children as part of their work. Staff had attended safeguarding training. Safeguarding training had not included safeguarding children; however, this was added to staff training records to complete during the assessment. The management team had reviewed processes and learnt lessons from safeguarding incidents. Staff understood their responsibilities to report a safeguarding concern. Staff were aware of the whistle blowing policy and told us they had access to all policies at all times. Staff told us they were confident to speak up if needed. A staff member said, “I have done safeguarding training. I would report abuse to my immediate team leader and record the evidence. It would be acted on.”

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found mental capacity assessments were in place for people lacking capacity to make some decisions and these showed who else was involved in the decision making, such as relatives. There was no capacity assessment or consent form for a person in relation to them having a sensor alarm, we reported this to the management team, and they took action to address this. DoLS applications and authorisations were in place for people around any restrictions within their lives that they did not have capacity to consent to. Systems to review these were also in place.

We observed interactions between staff and people during our visits. We saw safe practice whilst enabling people to maintain their routines and come and go around the service as they wanted. People told us they felt safe. Comments included, “I feel very safe here” and “I have felt safe here from the first time I moved in.”

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Risks to people in relation to harm from constipation were not always well managed. For example, action had not always been taken to give people as and when required laxative medicine when they were suffering from constipation. A person had not opened their bowels for 4 days. Their continence assessment showed they suffered with constipation but there was no guidance for staff to follow to indicate when this should be escalated. Actions had not been taken. We reported this to the management team. After we raised this, changes were made to the person’s care plan and risk assessments to make it clear to staff including staff to give medicines at what point constipation should be escalated to the GP. Another person’s care records evidenced they had reported constipation to staff. However, their care plan and risk assessments had not been updated to evidence they could be at risk of constipation and to detail what action staff should take, such as offering higher fibre foods, prunes, increased fluids or reporting on to the GP. The registered manager informed us after the assessment, that action had been taken to address this. A staff member said, “Constipation is a big thing for us, if I am worried about anyone, I would report it to the team manager. We do have high fibre foods we can offer; they rarely eat it though.”

Fire risks were mostly well managed, however fire drills had not always been simulated using reduced staffing (numbers associated with night shifts) to determine if staffing levels were adequate to meet people’s needs in an emergency. We reported this to the management team who agreed to carry out further drills. Appropriate fire detection, warning systems and firefighting equipment were in place and checked to ensure they remained effective. These ensured the provider was able to respond effectively to fire related emergencies that could occur at the service.

Most risks to people's health and wellbeing had been assessed and each person had personalised assessments, which identified the risks they could be exposed to, and the support needed to minimise these and to ensure their safety. However, the care plan for a person recorded they could be anxious and distressed on occasions. Other than staff offering reassurance, no risk assessment was recorded detailing the actions to be taken should they express their anxiety or distress in a way that may pose a risk to themselves or others.

Formal risk assessment tools, such as those to assess risks for people who were at risk of falls, developing pressure ulcers, or at risk of choking and aspiration, were routinely completed. These are crucial for ensuring people receive appropriate support to meet their needs. These provided clear guidance for staff on the preventative measures to ensure people’s safety.

Personal emergency evacuation plans (PEEPs) were in place in the service to detail people’s support needs if they required to be evacuated in an emergency. Not all people’s PEEPs detailed what help and support they needed after being evacuated. We reported this to the management team. They took action to update these to make it clear.

Relatives told us their loved ones were safe, and risks were managed.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. The building had generally been suitably maintained, however we identified 1 person’s bedroom flooring which had become damaged and a dirty pull cord in a bathroom. The registered manager took immediate action. The light pull cord was replaced and new flooring was ordered.

Essential servicing and maintenance of the service, utilities and equipment had taken place. The maintenance team carried out checks of the service including people’s rooms, they then completed any maintenance jobs that were needed. Although hot water outlets were tested at regular intervals to ensure the water emitted remained safe and within recommended guidelines, this was above the level considered safe. For example, some temperatures recorded were in excess of 44°C at the point of use. It was not evident that action had been taken to address this, which put people and staff at risk of harm.

A relative told us that the service was well maintained and timely action had been taken to make adjustments to meet maintenance needs in their loved one’s bedroom. We observed the grounds were well maintained and landscaped, this made the garden a secure and inviting place to spend time when the weather was nice.

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. However, staff had not always been safely recruited. All required recruitment checks had been carried out, and documents were all in date. However, not all staff files contained a full employment history and reason for gaps. Interview records had not been retained to evidence that this had been discussed and explored with staff. We discussed this with the management team and they took action to address this. The provider had retained copies of references, interview notes, photographic identification and Disclosure and Barring Service forms (DBS). DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

We observed there were enough staff on duty to support people. We observed call bells were answered quickly. People gave us positive feedback about the staffing levels. Comments included, “There are enough staff here for me. I can do a lot for myself. I don’t know about the other people”; “There is always someone around”; “I think that they have enough staff” and “Mostly there are enough staff. There are the odd days if someone phones in sick, when they are a bit short.” A relative said, “There is always enough staff.” The registered manager told us they adjusted staffing levels when required as and when people’s needs changed. This included one to one support for people when it was deemed necessary. They reviewed feedback from people, relatives and staff on an ongoing basis to make changes to meet people’s needs.

We received mixed feedback from staff about staffing levels. Some staff thought there were sufficient and others that they could be rushed. Comments included, “I don’t think there are enough staff in the mornings to meet people’s needs”; “Sometimes we are short, if there is only 2 on at night [registered manager] will book agency to make up the numbers, if we are short in the day [registered manager] she does not get agency, so sometimes we run with 4 carers on”; “Most of the time there is enough staff, if there is an accident or a fall it can be difficult” and “I think 5 or 6 staff is plenty to be on shift. Any less would be a bit of a rush. We can ask for more staff if needed.”

Staff had regular supervision meetings. Staff induction was a mixture of training and shadowing experienced staff to gain confidence and experience. The training matrix showed that most staff had completed mandatory training. At the start of the assessment no staff had completed specific training relating to learning disability and autism. At the end of the assessment, the registered manager told us 90% of the staff had completed this training. CQC registered providers must ensure their staff receive learning disability and autism training that is appropriate to staff members roles. Staff told us, “We do a lot of online training, we did have someone to come out and do moving and handling and deaf awareness training”; “If we need more training they bring it in” and “I did moving and handling training before I started and I did an induction and then shadowing. I shadowed for 2 weeks. They gave proper training even though I had prior care experience.”

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. The provider had systems and processes in place to assess and manage the risk of infection. The provider had a daily cleaning programme in place. The service employed housekeeping staff to carry out daily cleaning, cleaning schedules were in place which included deep cleans for people’s rooms.

The provider had plenty of PPE (Personal protective equipment) in place to keep people and staff safe. We observed that the staff were using PPE effectively and safely. Staff told us they had sufficient equipment and PPE to provide safe care. Staff had received infection prevention and control (IPC) training and were familiar with IPC processes to mitigate infection risks. A staff member told us, “There’s enough PPE, it is on every floor and in other places.” We were assured that the provider was promoting safety through the layout and hygiene practices of the premises.

There were no restrictions to visitors. We observed visitors coming and going freely during the assessment.People and relatives told us, “The home is very clean, it is cleaned daily”; “I have a very comfortable room. The building is okay. It is kept clean”; “I have a nice room upstairs with a toilet. It is kept clean and tidy, and the rest of the home is clean. We have cleaners here” and “It is absolutely clean. It is always spotless.”

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. The provider had systems and processes in place to manage medicines. These were not always effective. The provider’s medicines policies had not always been followed by staff to ensure medicines were managed safely.

During the assessment we found evidence that people had not been given PRN (as and when required) laxative medicine when they were constipated. The medicines administration record (MAR) for a person showed they had not been offered PRN laxative which they were prescribed despite having not opened their bowels for 4 consecutive days. It was evident bowel monitoring records had not been checked prior to making this judgement. There was no oversight of bowel records. We reported this to the management team; immediate action was taken to amend handover records to ensure more oversight of constipation risks.

We identified that stock counts of people’s medicines did not always balance with the records held. This meant there were medicines that were unaccounted for, and the provider could not be assured people had their medicines as prescribed.

Room temperatures were not recorded to check that medicines in stock were kept at safe temperatures detailed by the medicines manufacturers. After we identified issues around the room temperature checks a temporary thermometer was added to the room and a suitable thermometer was ordered. Fridge temperatures were recorded to ensure medicines were stored at the correct temperatures. However, the fridge temperature checks did not follow good practice guidance. We provided the management team guidance about recording maximum and minimum temperatures of medicines fridges.

Despite the evidence above, most people gave us positive view about their medicines support. Comments included, “When I have my medicines, the staff watch me swallow them. They give me them when I need them”; “I don’t have to wait long for them to give me my medicines. They watch me swallow the tablets I take. If I need anything at night, I can press my call button” and “I get my medicines when I need them. I take a lot of painkillers for my legs, they always ask me if I need them.” A relative told us, “He takes medication, and there haven’t been any issues with him receiving the tablets.”

Staff told us they had medicines training and were competency assessed. We observed the clinical room was clean, mostly tidy and well ordered.