Lucketts Farm

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. At our last assessment we rated this key question good. At this assessment the rating has changed to 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 regulations in relation to safe care and treatment, and staffing.

This service scored 47 (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 have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. Although incidents were documented, it was not always clear what action had been taken to prevent incidents from reoccurring or people from coming to harm in the future. We saw some positive examples of learning being discussed in team meetings, such as discussing if people’s medication was working effectively or how staff should support two people separately following recent incidents. However for the majority of incidents we reviewed, the action stated “monitored” or “management informed”. There was no information how they had been monitored, or if management had been informed what action they had taken. One person had fallen twice in the last year but in the incident reports there were no clear actions, or learning taken to prevent this person from falling in the future.

Another person frequently hit their head when they were distressed, yet the incident report from a recent incident simply stated “monitored” with no further detail on how they had explored what might have caused the person to do this. There was no information around if they had requested any medical advice for the injury, how it would be monitored or how staff could prevent the person from doing so in the future. In both cases despite these incidents, there was no effective risk assessment in place to set out how the service could protect these people from harm. This demonstrated the provider was not consistently learning from incidents.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. Though we saw the provider worked closely with partner organisation to support the needs of people, it was not always clear at what point staff should make referrals to partners if people’s health needs deteriorated. Guidance in place for complex health conditions such as epilepsy, constipation and for people who had fallen or were in distress was not robust to ensure all staff would know when to request medical support. Staff did not have a good understanding of epilepsy management. One person had epilepsy and a staff member told us, “If they had a seizure I would call 999 immediately”, however the guidance in place referenced first administering medication after 5 minutes, and then calling 999 after administering a second dose 5-10 minutes later. There was no explanation of why staff may need to administer this second dose after 10 minutes rather than 5, and staff were also not able to explain this. This risked causing delays in accessing crucial medical support and a higher likelihood of significant harm occurring. We saw some examples of positive partnership working, including with mental health services if staff had observed people’s mental health was deteriorating and staff working proactively with the diabetes team for 1 person to make sure this was well controlled and managed safely.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. We observed that staff were trained in safeguarding and were knowledgeable about when they might be concerned abuse and neglect was happening, and the action they would take to report this if they believed this was the case. One staff member told us “Abuse can be physical, emotional, sexual and neglect. I might suspect it if I saw bruises, behaviour changes or low self-esteem”.

However, staff did not have the information to be able to ensure people were being supported to stay safe as care documentation was not specific enough on how risks to people’s health should be managed. For 1 person who was at risk of hitting their head, the care plan stated if staff identified bruising to certain parts of the body they would not need to seek medical support in most circumstances as this fitted a regular pattern of behaviour. But the provider had not considered there may sometimes be other explanations for this bruising, or how staff would need to consider this and make referrals to partners to ensure this person was safe and not being exposed to a risk of harm and abuse.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. People lived with a range of complex health conditions including epilepsy, diabetes, increased risk of falls, constipation, distressed behaviour and poor skin integrity. However, the provider had failed to put in place robust guidance or risk assessments to demonstrate how staff should support people to manage these conditions to help them stay healthy and well. For example, multiple people were at a high risk of falls due to limited mobility yet the provider had not put in place a clear risk assessment showing how they had continually reviewed and assessed this risk, and any steps they could take to prevent people from falling. We identified 1 person was also being administered anticoagulants (medication to prevent blood from clotting), which meant if they did fall there was a significantly higher risk of suffering internal bleeding. Yet there was no information on this in their care plan on how staff should respond if this person were to fall, or the importance of seeking medical advice given the higher risk posed by their medication. The provider was in the process of moving to a digital care management system and following the inspection reviewed people’s care plans and risk assessments to add additional detail.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The provider had robust regular audits that ensured the safety of the environment for both people and staff, and actions were taken responsively if any risks in the environment were identified. This includes risk assessments for supporting people in access the wider community, for example around helping manage the risks of road safety and in travelling using public transport.

The provider did not make sure there were enough qualified, skilled and experienced staff. We found that staff were working lengthy hours that exposed both themselves and those they supported to a substantially greater risk of harm. A significant proportion of staff worked almost every day, and we observed 3 members of staff who had worked 29, 30 and 31 days respectively in August in a row without a day off. Staff we spoke to stated this was their choice to work these hours and they had not been pressured to do so and were able to take breaks during the day. However, the provider had failed to recognise that working such lengthy periods without a rest day whilst supporting vulnerable individuals would place people at significant risk of harm or mistakes being made.

One staff member told us, “Staff are working long hours which means mistakes can be made. New staff coming in are needed to reduce burden on the staff team”. Some people’s relatives also fed back that they had concerns with 1 relative saying, “There’s not enough staff, and there are only 3 in management…” The provider told us 3 new members of staff were starting imminently which they thought would reduce the pressure on existing staff members. We also heard examples of people not always being able to live life as they wished to due to staffing numbers, such as situations where people could not access the community due to operational pressures, or people being asked to leave their home because staff were going out with others and could not support them.

Although staff numbers and working patterns were unsafe, we found that staff were recruited safely with appropriate checks completed and that staff had appropriate training in the needs of the people they supported.

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. All staff had completed training in infection prevention, and there were weekly checks undertaken to ensure staff were working safely to reduce the risk of transmitting infections. Staff had a good knowledge of the steps they would take to ensure they were working safely, including when they would need to use personal protective equipment (such as gloves, masks and aprons). Where supplies of these were running low, this was picked up by the audits to ensure there was always access to these where needed.

The provider had not always 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. Where staff were supporting people to access medicines, the provider undertook a robust competency assessment to ensure they were sufficiently knowledgeable to administer medicines safely. People’s medicines were stored, administered and recorded in line with best practice. There were regular audits to check medication practices at the service were safe. If medication errors were made, staff explained they would immediately contact 111 to receive rapid medical input. Where possible, the service encouraged and empowered people to manage their own medicines independently with one relative saying, “Yes (person name) has access to all their medication and takes it independently, they know what to take and when, staff are very good with supporting them to do this”.

However systems and plans were not efficiently detailed to ensure people would then receive the medication they needed, when they needed it One person had epilepsy and was prescribed rescue medication if they were to have a seizure. The guidance in place was not specific enough on when the rescue medication should be administered and when medical advice should be sought. This meant staff were not clear on how they should respond to keep this person safe. None of the staff members we spoke to knew when to administer, all giving us different times at which they would do so. Another person had constipation but monitoring systems were not being used effectively, meaning staff couldn’t be clear on when they would need to administer medication.

Where “as and when” medicines were prescribed, the staff were not always recording if these were effective to monitor if medicines were helping people stay well. We did see some records demonstrating the provider had discussed internally and worked with external partners if they felt people’s medicines were not working effectively.