Lawnbrook 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. 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 regulation in relation to safeguarding.

This service scored 56 (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 systems in place to support a proactive and positive culture of safety, including processes for reporting, investigating and learning from incidents. Staff were able to report concerns about safety and incidents were reviewed and acted upon. Lessons were identified and shared to support improvements in practice.

There was a system in place for staff to report incidents and accidents and staff were able to contact a manager through an on-call system for out of hours guidance. Relatives were kept informed of any accidents or incidents which occurred.

Accidents and incidents were routinely reviewed by the management team to identify trends and opportunities for improvement. Lessons learnt were shared with the staff team through daily handovers and during staff meetings.

This meant that systems were in place to support an open and accountable approach to safety and the sharing of good practice across the staff team.

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 provider had processes in place to ensure relevant information was shared with other stakeholders and professionals when people were transferred to external services, such as hospitals. This included sharing key information about people’s needs to support safe and effective transitions.

Leaders told us they communicated effectively with external professionals, including GPs and hospital teams, to ensure people received coordinated care. Records showed referrals were made appropriately.

Systems were in place to support people when they returned from hospital, including reviewing care plans and updating risk assessments where required to reflect any changes in people’s needs.

The provider did not work well with people and partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

We identified shortfalls in systems and processes relating to safeguarding, including the management and oversight of people’s finances. Records were not always accurate, complete or up to date, and it was not always clear how people were being supported to manage their finances safely.

Financial recording systems for people did not consistently reflect correct balances, and some historic discrepancies could not always be fully explained due to gaps in record keeping. Concerns about the potential risk of financial abuse had not been identified.

In addition, limited transparency in some financial arrangements increased the risk of financial abuse. For example, where money received by the service from a person was passed to a senior manager for transfer to head office without clear documentation of the amounts handed over. The provider was not able to maintain a clear audit trail or fully account for all funds. While there was no evidence at the time of inspection to confirm financial abuse had occurred, the provider could not fully demonstrate that all monies had been managed appropriately. This meant systems to safeguard people from the risk of financial abuse were not sufficiently robust. The provider could not always demonstrate people’s money was safely managed or fully accounted for, placing people at potential risk of harm from financial abuse.

The provider was open and responsive to our feedback and took prompt action to review and strengthen their systems.

Where required, appropriate authorisations were in place to ensure people were supported safely. Deprivation of Liberty Safeguards DoLS applications had been made where people lacked capacity to consent to living at the care home.

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.

The provider had systems in place to assess and plan for risks. Care plans and risk assessments generally set out how risks should be managed and included guidance for staff to reduce the risk of avoidable harm, such as risks in relation to falls and constipation. However, we found some risks were not always effectively identified or consistently managed, which meant people were not always fully protected from potential harm. For example, risks in relation to the management of people’s finances had not been effectively overseen, placing people at potential risk. It was not always clear how people had been involved in decisions about managing these risks, or how their understanding and preferences had been taken into account.

People’s risks were reviewed regularly, and staff were updated through meetings, handovers and care records about changes to people’s needs and how these should be managed. While leaders described discussions with people and their families about risks, this was not consistently reflected in care planning records. This meant it was not always clear whether people’s views and preferences were consistently considered in how risks were managed.

Overall, systems were not always effective in ensuring risks were consistently identified, managed and reviewed in a person-centred way. This placed people at risk of receiving care that did not fully reflect their needs or support their safety.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

We identified shortfalls in fire safety systems and processes. While regular fire drills were carried out, records did not contain sufficient detail to demonstrate their effectiveness.

Although the provider told us recording formats had been updated following advice from the fire service, records did not clearly demonstrate that different fire alarm call points were tested. This limited the provider’s ability to evidence that systems were being routinely and effectively checked.

The provider told us they had begun taking action to address these concerns, including improving recording systems and strengthening oversight.

However, other aspects of the environment and equipment were managed appropriately. Equipment was generally well maintained, serviced and clean, and staff were trained to use it safely. Staff told us equipment was available when needed, which people also confirmed. Maintenance issues were reported and addressed promptly, and staff were able to describe the action they would take in the event of a fire, demonstrating they understood how to support people to evacuate safely.

Overall, systems to assess and monitor environmental risks were not consistently effective, particularly in relation to fire safety oversight.

The provider did not always ensure there were sufficient numbers of suitably qualified, competent, skilled, and experienced staff to meet people’s needs safely and effectively.

We identified shortfalls in recruitment records. The provider could not demonstrate that all required pre-employment checks had been consistently completed, or that staff records contained all required information. For example, some staff files did not include full employment histories. Although the provider told us these checks had been carried out, they were not always recorded and could not be verified at the time of our review. Following feedback during the assessment, the provider submitted additional information, including employment histories and explanations for gaps in employment.

Staff had received training and supervision, and records were available to support this. However, some staff told us they were not always actively involved in the supervision process. This meant records did not consistently evidence meaningful, reflective discussions about their practice and development.

Staffing rotas recorded when agency staff were used; however, they did not include the names of individual agency staff members. This meant it was not always possible to clearly identify who had worked each shift from the rota alone. This lack of clarity reduced the provider’s ability to effectively oversee staffing deployment.The registered manager told us that agency staff were communicated to the team through verbal handover processes, and that timesheets could be used to identify which agency staff had worked. However, this information was not clearly reflected within the rota records. There was no single, complete record of staffing deployment, which limited the provider’s ability to demonstrate effective oversight of how staffing levels were planned, monitored and maintained.

Feedback from people and relatives about staffing levels was mixed. Some people and relatives told us staff were responsive and met their needs promptly. However, others felt there were not always enough staff available to spend meaningful time with people or provide individualised activities. Some relatives also expressed concern that unfamiliar or agency staff may not recognise changes in people’s needs. Staff told us that additional responsibilities, such as domestic duties, could reduce the time available to support people, although all staff said people’s immediate needs were responded to promptly.

During the assessment, we observed there were sufficient staff available to meet people’s needs, and staff responded in a timely way. Staff demonstrated a good understanding of people’s needs. Systems were in place to support the use of agency staff, including induction processes and the sharing of relevant information.

The provider assessed and managed the risk of infection. They took action to detect and control the risk of infection spreading and shared concerns with appropriate agencies when required.

During our visits, we observed the home was clean and hygienic throughout. People and relatives told us the home was kept clean and cleaned regularly.

Personal Protective Equipment (PPE) was available and accessible across the home, and staff told us they had sufficient supplies to use when needed. Staff demonstrated an understanding of infection prevention and control practices.

The provider had an infection prevention and control (IPC) policy in place, which was accessible to staff and supported them to follow safe working practices.

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

We identified shortfalls in the management of variable dose and ‘as required’ (PRN) medicines. While staff were able to explain how they administered these medicines, and we observed appropriate practice, there was a lack of clear, recorded guidance to support consistent decision-making. Protocols did not clearly outline when specific doses should be administered, and the electronic system did not enable staff to record the rationale for the dose given. This increased the risk of inconsistent practice.

We also found that guidance for the use of topical medicines was not always clear or consistently applied. Although systems such as body maps were available, these were not routinely or consistently used in practice. This meant the provider could not demonstrate that staff had clear, accessible guidance to support the safe and consistent application of these medicines.

Therefore, the provider’s medicines systems and records were not always sufficiently robust to support safe, consistent, and person-centred practice. The provider responded to our feedback during the assessment and took action to review and strengthen these systems.

Medicines were stored securely, and records for medicines were accurately completed and appropriately checked. Stock balances matched records, and medicines were dated in line with good practice.