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. Some aspects of the service were not always safe. There was an increased risk that people could be harmed and not have their human rights protected. The service was in breach of legal regulations in relation to safeguarding and consent to care.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

People and their relatives stated they felt listened to. One relative explained how they had discussed some worries about their loved one's nighttime care needs, and within a short timescale, staff had taken action to make improvements.

Leaders described the way they should handle incidents, and safety concerns. They recognised that whilst most safety concerns were dealt with appropriately, there had been an occasion recently where improvements could have been made.

Accident and incident forms were completed when incident occurred. An accidents and incidents log was completed by the management team, which included a column for lessons learnt, however this was found to primarily describe a summary of the incident, as opposed to lessons which had been learnt following the incident. Actions taken aligned with the incident, and we saw evidence of referrals to other healthcare practitioners being made when appropriate.

We did not look at Safe systems, pathways and transitions during this assessment. There is no previous rating for the Safe key question so we cannot yet publish a score for this area.

People told us they felt safe living at Lonsdale Mews. Relatives echoed this feedback. One relative said, “I am very happy, [name] is safe there.”

Staff spoken with as part of this assessment were not able to describe the timescales in which incidents or allegations should be reported, as per the provider’s policy. Following a recent incident, we were also concerned staff did not report this in a timely manner, or to the appropriate department.

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. We identified shortfalls within the provider’s processes in respect of the management of these DOLS conditions. Some information was missing to enable for the provider to demonstrate all conditions were being met. Following our assessment, the registered manager advised they had updated their DOLS tracker to ensure they had oversight of this and supplied some additional which was unable to be located during our visit to the service.

People did not always experience care which supported them to manage risks in respect of their care and treatment. Some risks had not been adequately assessed, and the service did not always act in accordance with the requirements of the Mental Capacity Act 2005 and associated code of practice where people could not provide consent.

The registered manager acknowledged that some improvements could be made to risk assessments and proceeded to immediately update some to show the inspectors. The revised risk assessments contained much better guidance for staff to follow. They also acknowledged staff required further training around the Mental Capacity Act and provided us with confirmation this had been booked following our visit.

Some care records we reviewed lacked guidance for staff to follow to ensure risks to people were safely reduced. For example, one person’s wound care plan stated the person needed to be repositioned regularly to prevent further skin damage. However, the record did not detail how frequently staff should be completing this. There was also no guidance for staff to follow if the person’s wound dressing had come off.

People who had been assessed as lacking capacity to consent to some aspects of their care had best interest decisions in place. However, these lacked significant amounts of detail to explain why the decision which had been made was in the person’s best interests, how their previous life experiences and wishes impacted on the decision, and how family had actively been involved in the decision-making process. This meant staff could not always support people to manage risks around their care in line with their best interests.

People received care in a safe environment. The home had been purpose built and was designed to meet the needs of a variety of people, such as wide corridors to allow ease of mobilising for people who used a wheelchair. The environment was clean and appropriate safety measures had been implemented such as window restrictors to allow people to open the window in their bedroom safely.

People were cared for in an environment that met their needs. The facilities and equipment were well-maintained.

People told us they received care from sufficient numbers of trained and competent staff. People said they did not have to wait long for staff to come when they needed assistance, and relatives told us they could locate a member of staff easily when they wanted to discuss their loved one's care.

The registered manager advised they employed a high number of staff to ensure shifts were adequately covered, and the service also employed their own bank staff to support when permanent staff members were on annual leave or away from work. Most staff members spoke favorably about the numbers of staff on each shift.

We observed plenty of care staff on shift, including when we commenced our assessment with an unannounced out-of-hours visit.

The provider’s processes ensured staff received regular supervisions and appraisals. The provider’s records demonstrated staff received a variety of training, and competency checks to ensure the training had been effective for subjects such as moving and handling, were in place.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The home was kept exceptionally clean by the dedicated head housekeeper and their team. The housekeeping team had good knowledge of the appropriate chemical to use for each task.

We saw appropriate handwashing areas, and staff had ample supply of Personal Protective Equipment.

People received their routine medicines at the right time, from trained staff members.

Staff told us, and demonstrated, they were competent with safe medicine administration processes. People’s choices were respected when medicines were administered, 1 staff member explained how they ask people where they would like to take their medicines, for example in the lounge or in their bedroom.

We identified some shortfalls in medicines processes. For example, 3 sharps bins had not been labelled on opening, and information to support staff to administer when required (PRN) medicines was not always personalised. This included records for people’s PRN pain relief, PRN laxatives, PRN glucose gel, and PRN anxiety medicines. Medicines were stored securely, medicine rooms were clean and tidy, and records regarding medicine returns and destruction had been completed accurately.Following the inspection, the provider demonstrated they had taken action to improve the guidance to support staff to administer people's PRN medicines.