Lavender Fields

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 inadequate. 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 the safe management of people’s medicines.
 

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 have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice.

At our last assessment, people had accidents and incidents such as falls repeatedly, and specific action had not been taken to learn lessons to prevent a re-occurrence. We found people had fallen and sustained injuries more than once and they continued to fall without a prevention plan in place. Monitoring of accidents and incidents to improve outcomes was poor. At this assessment, improvements had been made, staff were recording incidents and there was better oversight by the registered manager.
However, the process for monitoring accidents and incidents and ensuring all staff learnt lessons from incidents to prevent a re-occurrence still needed a more robust and effective approach. Lessons learnt were often recorded on the electronic care planning system. However, there was not a consistent process in place to cascade the learning and check that all staff had read and understood their responsibilities to keep people safe from preventable incidents.

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.

At our last assessment, information about people was not adequately monitored to ensure it was up to date and accurate. This meant people were more vulnerable if being admitted to another establishment such as a hospital, as the information that went with them may not have provided an appropriate picture of their needs.
There was now a more robust approach to people’s safety and how this was managed. Care plans provided information that was more individual to the person and individual risk assessments were adequately assessed and reviewed. This meant information passed to other agencies such as hospitals and other care homes were up to date and reflected the needs of the person. People who were unwell and moving between services could now be assured their records were sufficient to ensure their needs could be met. Staff who did not know them would have the information to provide care and support because their needs and risks were adequately recorded and shared.
People had been referred to healthcare agencies such as GP, dietician, podiatrist and community mental health team. The provider and registered manager had engaged closely with health and social care staff at all levels and supported moves to different services if it was necessary following assessment of people’s needs.

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 were now protected from the risk of abuse and improper treatment. At our last assessment, the provider had not always been open and transparent and had not always referred incidents that may constitute the alleged abuse of a vulnerable adult to the local authority as per safeguarding protocols.
At this assessment we found improvements. The provider and registered manager had ensured they met their responsibilities. Incident investigations were completed and reviewed by managers. Incidents were referred to outside agencies such as the local authority and police when appropriate. People and relatives told us they felt safe. Comments included, “I do feel very safe” and “I know how hard they work to keep her safe”.
Where relevant, a Deprivation of Liberty Safeguards (DoLS) application had been made when people had been assessed as lacking the capacity to consent to their care and treatment.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

At our previous assessment we found risks to people's health, safety and welfare had not always been identified. Staff did not have the guidance necessary to reduce risks and provide safe care for people living at the service. During this assessment we found improvement in the identification and assessment of individual risk. People had assessments including areas such as falls, choking, nutrition, skin integrity, distressed behaviour and mobility. Care plans provided more detail about people’s personal circumstances and guidance for staff how to provide safe care. Where people had fallen and remained at risk of further falls, this was identified and guidance for staff in how to support independence while supporting people to be safe from injury.
Some risk assessments were of a good standard, providing individual information about the person and their risks, including what worked well for the person to enable successful risk prevention. The individual care plans and risk assessments for a person living with Parkinson’s disease were detailed. Providing an explanation for staff why it was crucial the person received their medicines on time and the impact on their health and wellbeing if their medicines were given late. This protected the person from avoidable harm such as falling and injury. However, the quality of risk assessment records was inconsistent, and not all individual risks had been identified. Other records contained basic and general information about a risk that did not specifically relate to the person. Further work was required to ensure all risk documentation was accurate and consistently linked to care planning.
People and relatives told us they were generally safer and risk management had improved. A relative said, “They’re much more helpful. It’s much better, it’s like a different place. The safety and the dignity are all better.”

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 environment was safe, free from clutter, and equipment and services were maintained well. At our last assessment, people who required the use of equipment such as hoists to move around were not always appropriately assessed to ensure their safety. This had now improved and staff were only using hoists and slings that were suitable and safe for people to use.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always work together well to provide safe care that met people’s individual needs.

We found improvements to staffing arrangements at this assessment. At our last assessment there were significant concerns about the numbers of agency staff being used to deliver people’s care. There were a substantial number of staff vacancy hours, and there were times when all staff on shift were supplied by an agency. This led to inconsistency affecting people’s wellbeing and safety. At this assessment, a number of new staff had been recruited. The number of people living at the service had reduced, so the provider had temporarily closed a floor to enable consistency of staff across 2 floors and therefore limiting the reliance on agency staff further. People told us they generally did not have to wait long if they needed assistance. Although some relatives felt staffing levels had improved, some were concerned about the numbers of permanent staff that had left. Comments included, “Staff are good, they do everything. There aren’t enough of them when you want to get up and changed”, “(My relative) concerns are the turnover of staff and temporary staff, mainly night staff, I suppose it’s across the sector” and “You want your relative to be seen straight away, but you have to understand other people have needs. Sometimes they say they have to go to help someone else and they’ll be back in a minute. You know you’ll have to wait a while, but you know you’re in the queue”.
People and relatives told us they were often running out of clothing such as underwear and nightwear as items sent to the laundry were not returned in a timely way. The registered manager acknowledged they had concerns regarding the laundry when they investigated during the assessment and confirmed they were taking action to address the issues.
Some staff told us they felt there were times when there was not enough staff on shift to provide the levels of care people needed. Staff felt this was often due to high sickness absences amongst some of their colleagues. When this was at short notice, replacements were not always available.
The skills of staff had improved and closer monitoring of staff compliance in completing training within the expected timescales was in place. Staff had been recruited safely; the required checks had been completed to make sure staff were of good character.

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.

The service was clean and the premises well cared for, supporting the prevention of infection spreading. A person told us, “It’s as clean as it can be”. Where people used a hoist to move around, the slings they used were no longer shared among numerous people. People had their own designated sling. Staff had access to personal protective equipment (PPE) when they needed it.

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

Medicines were still not managed safely. We identified multiple discrepancies between recorded stock balances and medicines remaining in stock. There was no assurance everyone had always received their medicines as prescribed. The discrepancies had not been identified through existing audit processes creating a risk people’s health and well-being could be affected and the cause not linked. People who required a patch to be placed on their skin for pain management did not have body maps in place for staff to record where they had placed the current patch. This was important as the manufacturer instructions state a patch must not be placed in the same place for 3 – 4 weeks to prevent skin irritation. Improvements had been made regarding people living with Parkinson’s disease receiving their time specific medicines on time. Staff responsible for administering medicines had their competency checked more regularly, however, the discrepancies found meant this could not be relied upon. Medicines governance arrangements were not sufficiently robust to provide assurance medicines were consistently managed safely and the importance of safe medicines administration was understood by staff.