CSL Lincoln

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. This is the first assessment for this newly registered service. This key question has been rated Good. This meant people were safe and protected from avoidable harm.

This service scored 69 (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.

Staff demonstrated a clear understanding of incident reporting and received effective debriefs to support learning when things went wrong. A staff member told us, “[After an incident] we would automatically get put in a team meeting. An email would be sent to the core team for debriefing and there would often be 1:1 meetings as well.” Although staff teams communicated effectively which reduced the risk of important information being missed after incidents, relevant details were not always added to support plans to help prevent recurrence.

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 service worked closely with people and their relatives to identify support needs and develop personalised plans before they began using the service. This approach ensured support was person-centred from the outset. When people were admitted to hospital, the service shared information with healthcare professionals to make sure individual needs were fully understood and continuity of care was maintained. These processes helped reduce stress for people and their families and supported smooth, well-coordinated transitions between 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.

People and their relatives reported they knew how to raise concerns and felt listened to. Observations indicated that people were treated respectfully and had established positive relationships with staff. Staff understood safeguarding responsibilities, could identify signs of abuse and knew how to escalate concerns appropriately. A staff member told us abuse could be identified in different ways for different people for example, a person could have physical signs such as injuries, or they may need to monitor someone’s body language and verbal cues.

Some people experienced restrictions due to lacking mental capacity to make safe choices, such as requiring 24-hour support or not being able to leave their home independently. The provider was working with social workers to reassess a person’s mental capacity and apply for a Deprivation of Liberty Safeguard (DoLS) authorisation if required. The DoLS procedure protects a person receiving care whose liberty has been limited by checking this is appropriate and in their best interests. This was a positive step toward ensuring restrictions were lawful and proportionate.

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.

Where possible, people were involved in decisions about risks and their choices were respected. However, systems to regularly check money kept in unsecured places, such as people’s purses, were not always in place, which created a risk of financial abuse.

Staff told us care plans and risk assessments generally provided sufficient information to manage individual risks. However, guidance on supporting people when distressed was not always clear, which could affect consistency and make it harder to ensure the least restrictive and most effective approach to minimise distress.

Emergency evacuation plans were not always clear and sometimes lacked key details about individual risks, such as the use of paraffin-based creams. Although person-centred, the plans needed further development to ensure they were suitable for use in an emergency.

The provider was responsive to feedback by introducing additional financial checks and starting a review of support plans to strengthen safety and reduce risk.

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

People were supported in safe, adapted environments. Buildings were managed by a specialist housing group. Although the provider acknowledged that improvements including safety improvements could take time, they ensured all necessary repairs and upgrades were completed.

Staff understood their responsibilities and used equipment correctly to keep people safe. Where possible, people and their relatives were consulted about the environment to ensure adaptations and reasonable adjustments met their individual needs and preferences.

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.

Robust and safe recruitment practices were in place to ensure all staff were suitably experienced, competent and able to carry out their roles. Staff rotas showed enough suitably qualified staff were deployed to deliver the support people were funded to receive.

Staff reported receiving inductions and felt training supported their roles. Some staff told us supervisions were inconsistent, while others found the frequency of them was sufficient. Inductions included shadowing experienced staff and completing competency checks to ensure the right skills and understanding to meet people’s needs and provide safe support.

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 were protected from infection risks through clean premises and equipment. People were supported to maintain personal hygiene in ways that promoted safety and reduced infection risks, while respecting individual needs and preferences.

Staff were trained and understood their responsibilities for maintaining cleanliness, personal hygiene, hand hygiene and correct use of person protective equipment (PPE).

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.

Medicines were stored, recorded, administered and disposed of safely, with effective oversight in line with legislation and guidance. Staff were trained and regularly assessed to ensure competence in safe medicines management. However, some staff were unfamiliar with Stopping Over-Medication of People with a Learning Disability, Autism or Both (STOMP), the NHS England programme aimed at reducing inappropriate prescribing of medicine that affects mood or behaviour. Although some progress had been made to improve staff understanding, this work was still ongoing.

Medicine records we looked at were complete, with no gaps or missing signatures and medicines were administered as prescribed. Care plans included details of the support required and people’s preferences for how their medicines were administered.