Lincoln Road

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 people’s safe care and treatment including medicines management.

This service scored 50 (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. They did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

There was a lack of oversight of incidents and accidents that occurred which placed people at risk of receiving unsafe support. For example, we saw on a body map it had been shared with the service that a person had unexplained bruising. There was no incident form in place for this, so this could be considered or investigated. The scheme manager told us the action they had taken at the time however there was no record of this for us to review.

In addition, there was no system in place that monitored incidents and accidents in the service to ensure appropriate action had been taken. We had to request individual incident forms were downloaded for people for us to review. There was no oversight of this information to identify any concerns or trends that were occurring in the home.

When incidents had occurred for people and they had been documented, there were not always records to demonstrate what action had been taken. Incidents had not triggered a review of the persons needs or risks to ensure these were being safety managed.

There was not always evidence to show how lessons were learnt and improvements made in the home where needed. When incidents had been recorded, it was unclear how learning had been implemented from these. The scheme manager told us lessons learnt was considered through incident and accident forms, however records we viewed did not support this and there was no section on these forms for lessons learnt to be considered.

The scheme manager talked us through an incident that had occurred and changes that had been made following this. However, there was no record of the changes made or evidence to show how these changes had been shared with staff. The staff meeting minutes we reviewed did not show information was shared. This meant we could not be assured that the learning culture at the service was consistently effective.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored.

There were systems in place to ensure people’s needs were assessed before they started using the service. However, this assessment did not always result in accurate and up to date care plans being produced to guide staff in how to provide safe, consistent care. For example, appropriate guidance was not in place for a person who lived with Epilepsy to ensure that staff managed their risks associated with seizures safely and consistently. However, the scheme manager told us they would complete face to face assessments with people and their families before they started using the service. They then had the opportunity to visit the home and spend time there. We saw pre assessments were completed before people started using the service which considered their individual needs.

The provider did not always ensure people were protected from the risk of abuse and avoidable harm.

The management team told us there were systems in place to monitor and act on safeguarding concerns. However, we could not be assured these processes were always followed. For example, we saw recorded on an incident form an incident had occurred between 2 people, which had resulted in an injury for 1 person. There was no record this incident had been investigated and the operations manager confirmed this had not been raised with the relevant agencies. We saw on a body map that another person had unexplained bruising. The scheme manager told us the action they had taken at the time the bruising was identified, however there was no record of this action for us to review or consider. This meant we could not be assured that people were consistently protected from the risk of abuse and avoidable harm.

However, people’s relatives raised no concerns about their safety. One relative told us, “I'll say, 'Have you had a good time? Is everyone nice and are you okay?' He always says 'Yes'.” Staff told us they had received training and were able to tell us the action they would take if they were concerned for people’s safety.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that when needed, DoLS were in place for people.

Risks to people were not always managed in a safe way.

Care plans were not always consistent, up to date or in place. Some of the care plans we viewed lacked detail or were not accurate. For example, in 1 person’s notes on admission to the home it was noted they had sore skin and their relation had advised action to take. There was no care plan or risk assessment in place for this and no records to confirm if this advice had been followed. Staff we spoke with could not confirm the advice had been followed.

However, people and relatives raised no concerns with how their risks were managed. We found some examples of some appropriate care plans and risk assessments that were in place for people.

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 and relatives raised no concerns about the environment, and we saw people appeared comfortable at the service. One relative told us, “It's so clean and tidy.” Where needed any risks to the environment or premises had been considered and assessed. For example, checks were being completed on water temperatures. There were processes in place to ensure any potential concerns or environmental risks were identified so that appropriate action could be taken.

The provider did not always make sure there were enough suitably trained or competent staff available to support people. There was no formal system in place to ensure there were enough staff available to support people’s assessed levels of need.

There was no effective oversight of training to ensure staff were suitably skilled to provide safe and effective care. An up to date training matrix was in place that showed us the mandatory training staff had completed. However, when people required specific training to ensure their needs were met, there were no records to show this had been completed. This included training in Epilepsy management, the administration of emergency medicines and Diabetes/insulin training. Although no one using the service at the time of our inspection lived with Epilepsy or Diabetes, the scheme manager and operations manager were unable to assure us they knew which staff had received this training. This meant effective systems were not in place to ensure suitable staff were available to provide safe care when people living with Epilepsy or Diabetes regularly accessed respite care at the service.

The operations manager gained this information from the training agency and shared this with us. These records showed not all staff had received Epilepsy management, Diabetes/insulin and emergency medicines training. In addition, when we spoke with staff who had received emergency medicines training as reported on under medicine’s optimisation, they shared conflicting information and 1 staff member told us they were not confident to complete the action they may need to complete. There was no competency process in place to show the provider had considered this. This placed people at risk of unsafe care or treatment.

There was no dependency tool used within the service to calculate how many staff were needed. The scheme manager told us they would have 2 staff on shift at all times as people had funding for shared hours. They told us if people required 1 to 1 support, then additional staff would be provided for this. The records we viewed did not assess people’s levels of dependency and therefore there was no system in place to ensure there were enough staff available to meet people’s assessed needs. Staff told us they felt there could be more staff. One staff member said, “Honestly, I believe it could be improved, it’s mainly when someone is off sick,there’s not enough cover it can be stretched.” Another staff member told us, “For day staff we have a lot of staff that come in from another unit for shifts.” Other staff raised no concerns.

However, on the day of the inspection we saw there were enough staff available for people, and they did not have to wait for support. As people went out to day opportunities we saw there were 3 staff available for 2 people. One person required 1 to 1 support, and we saw this was provided for them. People and relatives raised no concerns about staffing levels within the home and 1 relative said, “There's always 2 to 1 with him, usually it ends up more”. Another relative told us, “There's never been a problem with lack of staff”.

Staff had received the relevant pre-employment checks before they could start working with people to ensure they were safe to do so.

The provider assessed and managed the risk of infection.

People and relatives were happy with the cleanliness of the home. One relative said, “I've been there when it was a weekend and it's always nice, clean and calm.” Another told us, “They wear full PPE. He's never come home with an infection or smelly”. We saw the home was clean and people were protected from the risk of cross infection. Staff told us they had received training and there was enough Personal Protective Equipment (PPE) available for them to use. There were processes in place to ensure concerns with IPC were identified so that appropriate action could be taken.

The provider did not ensure people’s emergency medicines were safely managed.

When people were prescribed medicines for emergency situations relating to Epilepsy, the ‘as required’ plans in place lacked detail. For example, it did not say when these medicines should be administered. We discussed this with staff who gave us conflicting information. This meant people who were prescribed this medicine were at risk of not receiving it when they needed it. We reviewed training records for the administration of these medicines and found not all staff had received training in this area. We spoke with 1 staff member who had been trained, and they told us they would not be confident to administer this medicine. Although no one required this medicine at the time of our inspection, the systems in place to ensure the medicine could be safely administered when a person with Epilspy regularly accessed the service for respite were not effective.

We shared our concerns with the nominated individual, who told us they would implement staff training, competency checks and supervisions with staff. They told us they would introduce improved guidance and ensure there was a competent member of staff on shift to administer these medicines to people. We will review this as part of next inspection.

Other people received their medicines as prescribed. When people had other ‘as required’ medicines there was guidance in place for staff to follow. We saw medicines were stored safely and checks were completed to ensure stocks were accurate. Staff administering regular medicines had received training to ensure they were safe to administer these to people.

People and relatives were happy with how medicines were managed. One relative told us, “They look after his meds. I send enough with him. They'd let me know if anything happens. It was the same drug with a different name, and they were straight on the phone to check.”