Lonsdale Mews

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.

People and relatives knew how to raise concerns should the need arise, however, had not needed to do this to date. One person explained, “I have no complaints. If I did have a complaint, I would tell [unit leader].”

Staff knew how to raise concerns, if required. One staff member told us, “I have never experienced a safeguarding incident or had to report anything, but the management are good. I would feel able to report things and feel it would be acted on.”

There was a clear process in place for staff and leaders to follow if the event of an incident or accident. We saw staff and leaders had made timely records when accidents or incidents had occurred. These were reviewed, discussed, and any lessons learnt cascaded to the staff team.

The registered manager was confidently able to describe the processes they followed, including the escalation route should a serious incident occur. The registered manager told us if there had been lessons learnt in other homes across the group, these were cascaded to leaders, who could then also pass this information onto staff.

Where required, information had been shared with the partner agencies following an accident or incident taking place.

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.

People had a good experience of the referral and transition process when moving into Lonsdale Mews, or in the event they required conveying to hospital.

People, families and the care team worked together to formulate a robust care plan which comprehensively covered people’s needs when they moved in. One staff member explained, “Unit managers go and do a pre-assessment, we have a brief ‘heads up’ before the person comes on. They then come in, we sit and have a chat, find out their likes and dislikes, preferences, how they mobilise, get a discharge summary from the GP with all their medicines. Then we create a care plan with the person and family.”

Relatives told us they were kept up to date when their family member had been admitted to hospital. A relative stated, “[Loved one] was admitted to hospital last August after a fall. Staff dealt with the situation rapidly and kept me informed of what was going on. The same happened when [loved one] was discharged back to the home.”

The provider had a detailed service user guide and welcome information for people moving into the service.

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 told us they felt safe living at Lonsdale Mews. Relatives echoed this feedback. One relative told us, “I am happy [loved one] is in a place of safety.”

The provider had a robust safeguarding policy in place, which had now been shared with staff. Staff could now confidently explain the process they would follow in the event of a safeguarding matter occurring, however, were still unsure on the precise timescales for reporting as set out in the provider’s policy. There was no evidence safeguarding matters had not been reported in a timely manner because of this uncertainty.

People were observed to be treated well by staff. Signage was observed in the reception area and around the home promoting safeguarding.

Several people living at the service had Deprivation of Liberty Safeguards (DoLS) in place. Some people had conditions attached to their DOLS authorisation, which the provider was expected to meet.At this assessment, the provider was able to evidence they were meeting all of people’s conditions where applicable. The provider had also reviewed their DoLS tracker since the previous assessment and made this more robust to ensure leaders had better oversight in this area.

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.

People told us risks were managed well, and they were safe living at the service. One person stated, “I’m cared for here and I feel very safe. I don’t have falls here.” Relatives provided positive feedback about the service reducing the risk of harm or injury towards their loved one wherever possible. A relative told us their family member had mobility assessments and aids in place to try and prevent falls. Another relative explained their family member had a sensor mat at the side of their bed to alert staff should they get up in the night, to enable staff to go and help them.

Staff could detail the risk mitigation documents in place for people, such as risk assessments, clinical risk assessments and Speech and Language Therapy (SALT) assessments (for people who were at risk of choking).

The registered manager understood positive risk taking and the benefit this brought to people. They provided a detailed example of how a person had been supported to begin cooking again, and completing household tasks to enable them to return back to their own home, instead of needing to stay within a care setting.

Staff had received a variety of training in specific health needs and conditions such as choking, mobility and dementia to ensure they were knowledgeable in these areas, understood the risks and how to reduce these.

We observed a couple of people living with dementia to become disorientated in the afternoon and become distressed due to this. Staff intervened immediately, providing reassurance and reorientation, which swiftly helped people to feel much calmer. This prevented their distress escalating to levels which placed themselves or others at risk of harm.

The provider had a robust risk management policy which was reviewed regularly.

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 lived in a safe environment which was conducive to meeting their care needs. Bright and wide corridors, a variety of communal areas including lounges, dining areas, a café and a small shop, some smaller seating areas, and personalised bedrooms meant people had space to move around freely and a range of options of where they spent their time. People had access to the well-maintained and attractive gardens.

We observed the building was kept in good order, with appropriate signage, adapted bathrooms and clear access to fire exits. The service had a well-stocked emergency grab bag kept in the reception area, containing numerous items including torches, hi-visibility jackets for staff and foil blankets for people living at the service. Regular fire alarm tests and drills took place.

The service had regular health and safety checks completed on areas such as water temperatures, electrical wiring and gas safety.

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.

The provider was able to demonstrate care staffing rotas aligned with the dependency tool to ensure people’s needs could be met safely. People had their needs met in a timely manner, and relatives stated the care delivered was very good. No one raised concerns about long waiting times for support from staff, or that they had been impacted by low staffing levels.

We spoke with 10 staff during our assessment, and 8 of the staff raised concerns about staffing levels, however, were clear they did not let this impact people’s basic care needs. We addressed this with the provider, who explained that the home had been in its commissioning phase which meant staffing ratios were higher, whilst they waited for people to move in and the home to reach full capacity. However, as the home was now reaching full capacity, the staffing dependency tool was now accurately being adhered to, which may impact on staff feeling like levels had dropped. The provider advised they were going to discuss the dependency tool with all staff members to ensure they had a good understanding of how staffing levels were calculated and involve staff in reviewing this to allow staff to raise concerns if they felt the prescribed staffing levels did not align with people’s requirements.

Staff received robust training in a wide range of topics, to ensure they were competent to meet people’s needs. People and relatives told us they felt the staff had the right training to fulfil their roles.

Staff had been recruited safely, and thorough background checks had been completed on all staff prior to them commencing employment. Staff had completed health questionnaires to ensure the provider could make any reasonable adjustments where needed. Staff received supervisions, and an annual appraisal.

The registered manager described how staff were encouraged to develop their skills in line with their interests and goals, and how poor performance would be managed if the need arose.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

During the assessment we identified 1 mattress which had a compromised cover, which permitted bodily fluids to enter the foam inside. We also identified some stained bedding which had been put inside clean covers. This was raised with the staffing team and leadership team, who took action to rectify this.

We observed limescale build up on some ensuite taps and shower heads, and a small amount of exposed porous wood on doorframes which meant the housekeeping team were not able to clean this area effectively.

The rest of the home was clean, tidy and sanitary. A new head housekeeper had just commenced employment and was in the process of reviewing existing processes and staffing levels with a view to making the necessary improvements.

Staff had received training in Infection, Prevention and Control, and had access to a plentiful supply of PPE.

The registered manager was aware of the process to follow and who to report to, should an infectious outbreak occur.

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

People received their prescribed medicines in tablet and liquid form safely. However, we found creams were not being applied consistent with the prescribers instructions. A number of people living at the service required assistance with creams being applied to their skin, and this was managed by care staff usually during personal care as opposed to senior care staff who oversaw the medicine rooms and medicine trolley. For example, a person was prescribed cream to be applied once a day, however we found 13 occasions over a month where this had not been recorded as being applied. Another person required cream to be applied 2 to 3 times per day; however, their records did not reflect this was occurring. We raised this with the leadership team, who stated creams were being applied as prescribed, however, they were unable to demonstrate this within their records. The registered manager advised they would review and improve their current process to ensure this was rectified with immediate effect.

Not all records were clear, and updated when things had changed in respect of people’s medicines. For example, a person was observed to be given their medicines in a different format during the medicine round, however, their care records had not been updated to reflect the change. Another person had unclear information within their care plan regarding their ability to swallow their medicines.

Senior care staff were knowledgeable and competent in the administration of medicine and had all received robust training. Medicine rooms were observed to be clean, tidy, and well-stocked. People who prescribed medicines to be taken as required such as painkillers, had appropriate protocols in place to guide staff in when they should administer these if the person was unable to accurately communicate this. Medicine fridge temperatures were recorded as per best practice guidelines.

Medicine audits for tablets and liquids had been completed; however, improvement was needed in the auditing and oversight of the application of prescribed creams.