Archived: 1 Lansdowne 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.

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.

We could not be assured that the service always had a proactive culture of safety. For example, safety concerns related to medicines were not always appropriately identified. Leaders had not taken prompt action when there were allegations about staff conduct towards people. These concerns are referred to in more detail in the "Safeguarding and Medicines Optimisation part of the report."

However, when a person had experienced falls, staff had documented this and leaders had discussed actions that could reduce risks with staff during team meetings. The Manager told us in relation to accident reports, “I will read through them and look at any actions that need to be taken.”
 

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Records evidenced people had been supported to access external health professionals appropriately and when needed.

People were not always protected from abuse or improper treatment. When concerns about staff conduct were brought to the attention of the Manager, they did not always take appropriate action to safeguard people and staff while the concerns were investigated. This increased safeguarding risks to people, and the staff members not being protected if these concerns were unfounded. Action was taken after we followed up on these concerns by the provider.

However, staff had received safeguarding training and knew who they could report concerns to externally if they needed to. People we spoke with told us they felt safe.
 

The provider had not always managed risks safely and appropriately. For example, we observed that 3 people had returned home from the day centre in a taxi without staff support. When we enquired about this, the Manager told us that this should not have happened and shared a risk assessment for one of the people. This assessment stated that in an emergency, a 'more able' person who receives support from the service should be with them. This was not appropriate as a person using the service would be responsible for other people. We could not be assured that the service always safely and appropriately managed risks to people.

At the time of our assessment, not all people's care plans contained up-to-date information about managing risks people could experience. However, the Manager, who had recently started, was in the process of updating care plans.

Staff were knowledgeable about the risks people could experience, and could tell us how they supported people safely. For example, a staff member told us in relation to supporting a person who could experience falls, “I walk with [them] moving objects out of the way, trying to keep [person’s] room clear and ensuring [they] are wearing the right shoes.”
 

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

During our first visit, we identified concerns such as radiator covers not being fitted to all radiators. The Operations Manager informed us that these measures had been in place previously but were not replaced by the provider upon removal. They confirmed people may be higher risk from uncovered radiators due to their mobility needs and health conditions. A potentially hazardous cleaning product had been left unsecured in the laundry room. A window restrictor had not been fitted to a 1st floor communal space, and other window restrictors had not been equipped with tamperproof screws in line with the Health and Safety Executive's guidance.

We observed 1 person’s wardrobe was damaged and nails were exposed towards the rear. This had not been made safe while awaiting a replacement.

However, the provider met requirements in relation to fire, electrical, and water safety, and these were managed safely. Records showed staff had reminded a person what to do when the fire alarm went off during a drill to promote their safety. People had been supported with assistive technology such as call bells to promote their safety.

The provider made sure there were enough staff, who received effective support and supervision. We reviewed staff files and found staff were recruited safely. A relative told us, “There always seems to be enough staff for [Relative’s] needs.

We identified that staff had documented the fridge had exceeded safe temperatures on several occasions, but did not specify if they had taken corrective action. This increased risks to food safety. This concern had been previously highlighted to the provider following an Environmental Health Officer's visit in November 2024. We raised this concern with the Manager, who, in response, adjusted the recording times for fridge temperatures and identified the need for the provider to purchase a new fridge. During our first visit, we found that communal bathrooms had not been thoroughly cleaned. A bin and radiator in one of these bathrooms were rusty, and the sealant had failed; meaning they could no longer be effectively cleaned.
However, other communal areas and people's bedrooms were clean and free from malodour.
 

The provider did not always make sure that medicines and treatments were safe.

We observed that 2 people had topical medicines in their bedrooms that were no longer safe for use based on expiry dates or the date of opening. We reviewed the temperature records of 3 people's medicines and found that they exceeded safe storage temperatures on several occasions. Although staff had at times placed ice packs in people's medicine cabinets, there was no evidence that they had rechecked these to confirm the temperatures had been reduced suitably. The Manager told us they had not sought advice from a professional, such as a pharmacist, to confirm these medicines were still safe and effective. This also meant that, although staff had received medicines training, we could not be assured they always knew how to escalate medicines safety concerns.

However, we found that people's independence was promoted with their medicines. One person told us, "I take my meds on my own, but staff come to check the number of tablets I have left." People had their own medicine cabinets in their rooms, which promoted their privacy.