Lychgate House

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 people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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 a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The management team used systems to actively identify incident trends and patterns, including situations where people expressed emotions that may have increased the risk of incidents occurring. Staff shared learning from incidents, discussed themes in team meetings, and used this information to improve practice and outcomes for people.

The provider told us, “We consider what happened, whether there were any contributing factors and what lessons can be learnt. Where necessary, we introduce action plans, additional training, competency checks or changes to procedures to reduce the risk of recurrence.”

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 actively sought support for people to ensure people had continuity of care. Staff Supported people to attend healthcare appointments when required. A relative told us, “They are really good in supporting [family member] to access appointments, I will take them but as I work full time, they really do support me. They are really good.”

We did receive feedback related to slow responses from external agencies when people were referred, however, the service was proactive in following up delays and seeking the right support.

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.

Staff understood their safeguarding responsibilities and demonstrated knowledge of how to recognise, respond to, and report concerns. The provider had effective safeguarding policies and procedures in place, and staff told us they would not hesitate to raise concerns and were confident action would be taken. Records showed safeguarding incidents were reported appropriately, investigated where required, and shared with relevant agencies. Managers monitored safeguarding concerns to identify patterns, trends and learning opportunities, helping to improve people's safety and wellbeing.

People told us they felt safe and supported by staff who treated them with kindness and respect. A staff member told us, “If I suspect abuse, I report it immediately to the manager or senior staff and record the concern clearly. We follow the safeguarding policy and escalate to the local authority if needed.”  

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. Staff and management worked within the MCA. DoLS authorisations were appropriately applied for and overseen.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People were supported to make decisions about activities, relationships and daily routines that were important to them, with staff enabling them to take positive risks where appropriate.

Care plans and risk assessments were personalised and reflected people's individual needs, strengths and goals. They clearly identified specific risks and included detailed guidance for staff on the actions required to reduce or manage these risks safely and consistently. Areas assessed included mobility, falls, nutrition and hydration, medicines, physical health, mental health, behaviours of concern and risks associated with community access. Staff told us they were kept up to date with any changes. A staff member told us, “I am kept informed through handovers, care plans, daily notes, and communication from senior staff. Any changes in risk are shared immediately so we can respond safely.” 

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Since the previous inspection, the provider had addressed identified environmental risks by securing wardrobes to walls, reducing the risk of injury and demonstrating a commitment to continuous improvement. The provider also completed a fire risk assessment to ensure compliance with updated fire safety regulations and had started work to implement the recommendations and further strengthen fire safety measures within the service.

The provider maintained premises, equipment and utilities safely, ensuring regular servicing, maintenance and safety checks for gas, electrical installations, water systems and equipment in line with legal requirements. The provider monitored the environment through routine audits and inspections, enabling staff to identify and address hazards promptly. Equipment used to support people's care remained well maintained and available when needed.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

People told us staff were available when they needed support and did not have to wait long for assistance. A person told us, “Staff are a great help and all of them are helpful. There are staff around when I need them.” A relative told us, “I think there is enough staff.” Our observations on the day of the inspection indicated there were enough staff to meet people’s needs and respond quickly.

The provider followed safe recruitment processes to help ensure staff were suitable to work with vulnerable people. Recruitment records included application forms, interview records, references and Disclosure and Barring Service (DBS) checks before staff started work. A minor gap in one staff member's employment history had been identified and appropriately followed up by the registered manager.

Staff completed mandatory training relevant to their roles and received additional training to meet people's specific needs. Staff told us they felt well supported by managers and had opportunities to discuss their development and practice. One staff member said, "The training supports me in carrying out my role safely. When a specific need is identified, such as catheter care, diabetes, or behaviour support, additional training is provided." Another staff member said, “I receive supervision every three months; we review my progress from the last three months and set goals for the next three months. We discuss annual leave, sickness, risk assessments, professional growth, reflective practice, any mistakes or learning points, teamwork, e‑learning progress, policies, rota and feedback.”

Staff demonstrated a good understanding of people's needs and worked together effectively to provide consistent care and support. These arrangements helped ensure people received safe, person-centred care from staff who had the skills, knowledge and support needed to perform their roles effectively.

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.

Staff followed infection prevention and control (IPC) procedures and had access to appropriate guidance, training and personal protective equipment (PPE).

The provider maintained a clean environment and implemented cleaning schedules to ensure communal areas, bedrooms, bathrooms and equipment remained hygienic. Staff completed cleaning tasks regularly and the senior team monitored these through audits and spot checks. The provider also maintained adequate stocks of PPE and cleaning products, ensuring staff had the resources they needed to work safely.

The provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Medicines were stored, managed and administered safely. Protocols were in place for administration of medicines given on an ‘as required’. Staff completed medicines training and competency assessments to ensure they had the knowledge and skills required to administer medicines safely and effectively. Managers carried out regular medicines audits and checks to identify any errors, monitor practice and drive improvement. A staff member told us, “I feel the training provided has been sufficient and has given me the confidence to administer medication safely. I have completed online medication training and attended face-to-face medication training sessions. The registered manager also provides practical face-to-face medication training, which I have participated in and found very helpful.”