Lark View Care Home

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 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 staff recruitment.

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.

The provider did not always maintain a proactive, positive safety culture grounded in openness and honesty. Staff did not always listen to safety concerns or investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. There were systems in place to record and analyse accidents and incidents, identifying any patterns or trends. Audits had been completed, with an analysis showing very few falls. Action plans had been put in place to reduce the risk of them happening again. However, the falls risk management audit showed some care plans had not been updated with the action identified within the falls audit.

Staff told us they were kept informed of any changes to people’s needs during handovers at each shift. People told us they felt safe living at the service, and staff supported them to use the equipment they needed to remain safe. Relatives explained the action taken when their family member fell, “(Relative) has had a fall. They have installed a sensor mat. They did discuss this with us and explained everything.’

The provider worked well with people and healthcare partners to establish and maintain safe systems of care. They managed or monitored people’s safety. They ensured continuity of care, including when people moved between services. People met with the management team before moving into the service. A pre-admission assessment form was completed, covering all aspects of people’s needs. We reviewed a person’s assessment during our on-site assessment. The form had not been fully completed or signed by the person who completed it. This was discussed with the registered manager, and a completed form was received, which had more detail about the person’s care and nutritional needs. Following the inspection we reviewed more pre-admission assessment which contained detailed information about people's needs, choices and preferences.

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. Effective systems were in place to recognise and act on safeguarding concerns. The registered manager understood their role and raised concerns with the local safeguarding authority for investigation.

Staff had received training and could describe the signs they would look for to recognise abuse or discrimination. Staff were confident to raise concerns with the registered manager, and they would take the appropriate action.

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 how the service was managing DoLS within the service. We found that DoLS had been applied for as necessary. There was a process in place to track and monitor applications and when authorisations needed to be renewed. When authorisations had been received, these had been recorded in people’s care plans; there were currently no conditions on the authorisations in place.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care that was safe, supportive, and enabled people to do the things that mattered to them. Potential risks to people’s health and welfare had not always been assessed, and there was not always guidance in place to mitigate the risks. People’s care plans did not always contain the guidance staff needed to help them recognise when people were unwell. For example, some people were living with diabetes, their care plans did not always contain accurate details about what type of diabetes they had or the equipment they used to monitor their blood sugar. One person was at high risk of low blood sugar, and their insulin was being adjusted by the diabetic nurse. However, there were no details about how the person would present when they were unwell, including the range their blood sugar should be in. Following our on-site assessment, the care plans were updated to include the required information.

People’s care plans did not contain all the information required to reduce the risk of infection. Some people had a urinary catheter to drain urine from their bladder. Care plans stated leg drainage bags should be changed every 7 days; however, it did not state what day of the week this should be or where to record the change. There was a risk that staff, including agency staff, would not know when the drainage bags needed to be changed. The registered manager told us where the changes to the bag should be recorded. We reviewed the records of 2 people; there were limited records of the drainage bags being changed. For example, there was no record that a person’s drainage bag had been changed between April and October 2025. Where possible, we checked with people if their catheter bags had been changed; however, we could not confirm regular bag changes for everyone with a catheter.

When people were at risk of choking and required a specific diet to reduce the risk, there was no guidance about how to recognise if they were choking and the action required. Following our on-site assessment, an updated care plan was received. However, the guidance had not been checked to ensure it was relevant to the person and contained accurate information. Some people had developed pressure sores or skin tears; these areas had been treated appropriately, but people’s care plans had not been updated with the additional risks and how to reduce them.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. There were systems in place to make sure the environment and the equipment which people use were safe. There was a maintenance team given autonomy to decide what work was needed. The team would communicate the work needed and when it was completed with the registered manager. The maintenance team told us they were proactive and supported by the registered manager in making decisions about work before it became essential or unsafe. The maintenance kept records of all the regular checks they completed, including fire equipment.

The provider did not always ensure there were enough qualified, skilled, and experienced staff. Staff did not always work well with the provider to deliver safe care tailored to people’s individual needs, and recruitment practices were not consistently robust.

We found shortfalls in the processes to recruit staff; references from previous social care employment had not been obtained. Some recruitment files lacked employment references, or the references were from colleagues rather than the employer. Some application forms were not detailed and did not include full addresses or dates of employment. We discussed this with the registered manager, who had not been aware of the shortfall.

There was a core team of permanent staff; however, there were vacancies which were covered by agency staff. People and relatives expressed concerns about the use of agency staff, as they felt, at times, there were too many of them on shift, and they did not know how to support people. We discussed the amount of agency hours used each week with the registered manager, who explained how the vacancies had occurred, including the result of disciplinary action.

People and relatives told us there was not always enough staff, especially on the residential floor where there was a single staff member at night, as they sometimes had to wait. A relative told us, “Some staff are very good and make sure this is done before that go. They are short staffed which is not their fault.” Another person commented, “They are all very nice but not always enough of them. Nights are worse than days. There is only one at night. They do say that they can call someone on the other floors, but this is not always convenient if more than one person is buzzing. There are a lot of agency staff who do not know what they are doing. There are not always enough staff at mealtimes. Sometimes it is just one person dishing up and serving. Some people need assisting.”

The registered manager used a dependency tool to calculate how many staff were needed. We reviewed the staff rota; there was the calculated number of staff on duty. However, staff told us there were just about enough staff, but staffing levels did not allow time for staff to do extras, such as completing care plans. We discussed these concerns with the registered manager, who explained there were staff being recruited and they were waiting for the recruitment checks to be completed. There had also been a short trial of some staff starting earlier to help people get up when they want, it had been successful and will be extended.

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. Staff wore personal protective equipment (PPE) such as aprons and gloves when appropriate. There were supplies of PPE available around the building. People told us their rooms were cleaned regularly including changing their sheets.

There was a dedicated housekeeping team, who worked over 7 days. The head housekeeper managed their own team, making decisions and delegating tasks. People’s rooms were deep cleaned each month, equipment such as slings were washed regularly, records confirmed this had happened. Infection control audits had been completed, and any shortfalls had been rectified.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning. The systems and processes in place were not effective in making sure medicines were managed safely. People had not received their prescribed medicines. People’s medicines were ordered every month to follow a 28-day cycle. When people were admitted to the service or started a medicine during the 28 days, additional stock would need to be ordered to make sure they were on the cycle. However, this had not been completed, so some people would always run short of tablets at the end of the cycle. This had not been an issue, as the new stock of medicines had been delivered 7 days before it was due to start, and staff had taken the new supply to make up the shortfall. However, the medicines for December were delivered late, arriving 2 days before they were due to start during our onsite assessment. This had caused some people to be without certain medicines for up to 3 days including blood pressure tablets and diuretics, to reduce fluid build-up, placing people at risk of their health deteriorating.

Staff had not followed best-practice guidance regarding storage and the continued prescription of the medicine. When people were prescribed medicines in an emergency, they were not stored or followed up correctly. For example, the out of hours GP had written an emergency prescription on a piece of paper Staff had transcribed the instructions onto the medicine administration record (MAR), which had not been removed or checked with the person’s own GP to see if the prescription should be continued. There was a risk that people would be given medicine they were not prescribed

Some people’s stock medicines did not match the numbers on the MAR chart; discrepancies were found across a variety of medicines. For example, a person’s MAR stated there should be 45 Docusate tablets, but there were 77 available, and another person’s MAR chart stated there were 12 codeine phosphate tablets, though there were 15 in stock. We could not be assured that people had received their medicines as prescribed or staff understood how to record stock and when medicines had been given on the electronic system.

When people were prescribed medicines on a ‘when required’ basis such as pain relief or anxiety medicines, there was not always guidance for staff. Some medicines did not have guidance about when to give the medicine, how often and what action to take if the medicine was not effective. There was a risk people would not receive their medicine consistently to meet their needs.