Lyndon Croft

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

Systems to assess, monitor and mitigate risks to people, including risks associated with the support planning, risk assessment, and medicines management were not robust or effective. Staff had not always been provided with clear guidance on how to safely meet people's individual needs and manage risks. Where incidents had been recorded these had not always been reflected in people’s support plans and risk assessments to ensure people were always safe and staff were aware of such risks. We identified some areas of improvement in relation to infection prevention and control (IPC). The guidance for staff to follow on safe administration of medicines was not robust. We found medicines were not always administered as prescribed. This was a breach of Regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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.

Relatives told us they knew how to speak up if they had a concern about their loved one’s safety. Most people and their relatives told us they felt these issues were addressed by the registered manager when brought to their attention. However, some relatives told us they felt overall communication with the service could be improved. People and relatives told us about the positive changes within the service. Some told us the telephones were now answered but this seemed to still be an on-going concern for some particularly at the weekends. Others told us about raising concerns about getting in and out of the building. Some felt this had improved whilst others said it was still difficult. We were also told that most people and relatives were kept up to date when any changes occurred around people’s support needs and changes to support plans were made in accordance with these.

Staff told us they had received training to help them manage risks associated with people they supported. However, we found that some staff who had been employed for a long time had not completed mandatory or refresher training. Most staff we spoke with demonstrated their learning from the training they had received, for example in relation to moving and handling, fire, Mental Capacity Act (MCA)/best interest decisions and Deprivation of liberty Safeguard (DoLS). Most staff told us they could make suggestions in relation to people’s support needs and any changes to improve care. One staff member said, “[Name] the registered manager has an open door. If I see that we could put things in place here to improve care and teamwork, I share with [Name] registered manager.” The registered manager understood their duty of candour responsibilities. Staff told us there was a positive impact from lessons learnt which were discussed at staff meetings and supervision.

There was a system in place to review incidents and take learning from such events. The management team told us how they analysed information and used this to make positive changes within the service. However, we found these were not always effective and embedded to drive improvements. A lack of consistent guidance for staff in relation to people's individual needs and risks meant a proactive culture of safety was not always demonstrated. Body maps and skin integrity plans were not always reviewed and updated frequently to evidence that bruising, skin tears and pressure areas were closely monitored for improvements or deterioration. These records did not always reflect involvement of the district nurse team. Staff did not consistently report incidents such as when medicines had not been administered on multiple occasions due to the person being asleep. As a result, this issue had not been reviewed. This meant opportunities for learning and improvements to people’s care were sometimes lost or delayed. Where people were expressing physical or emotional distress additional support from health professionals was sought. We saw evidence of lessons learnt and changes implemented based on positive and negative feedback from people using the service and health professionals.

Relatives told us overall they felt informed and involved when their loved one was moving into the service. They also told us they felt confident that people’s safety was managed and referrals to other health services were carried out in a timely way.

Support plans for people did not always include key pieces of guidance for staff when supporting people to maintain their independence, choice and preferences. Although staff told us and we observed how they supported and responded to these, the provider had new staff who were less familiar with people living at Lyndon Croft. The registered manager told us they would address these shortfalls in the support plans and started to make such changes during the assessment process. The registered manager told us how they worked closely with other health professionals and had tried to develop strong working relationships to improve the service for people. Staff told us they felt supported and had all the information they needed to support new people moving into the service.

There were no concerns raised by commissioners in relation to the admissions or discharges within the service. A health professional told us how the care and support had improved in recent months.

Processes did not always ensure staff supporting people had clear guidance on, and awareness of, their individual needs and risks to keep people safe. We found no evidence this had caused harm to anyone. However, the lack of key information and robust support plans placed people at increased risk of inappropriate care and unmet needs. Reviews of people’s needs, and support plans were not robust or inclusive. The registered manager and regional manager had taken actions during the assessment to address these shortfalls and improve their processes.

People and relatives told us they understood how to raise any abuse concerns they may have. Relatives we spoke with told us they felt their loved ones were safe being supported by staff and did not have concerns about their safety. One relative told us, “If any safeguarding concerns arise these are shared with us and actioned.”

Staff told us they had received safeguarding training and could describe circumstances which would lead to them following the service’s safeguarding policy and procedure. However, we found not all staff had felt confident or had the correct awareness to identify and raise safeguarding concerns. We also identified records demonstrating one person who was expressing thoughts of harming themselves were not reflected in their support plans and had not been referred to the local safeguarding team. This placed people at risk of harm. The registered manager had identified this shortfall and provided additional training to improve staff knowledge. A cook we spoke with was unable to clearly tell us how they ensured people’s individual dietary requirements were met through the safe preparation and serving of meals. Leaders investigated and shared safeguarding concerns with the local authority’s safeguarding team when they were identified. All staff we spoke with were aware of the whistleblowing hotline which was available for them to use should they wish to report concerns.

We saw that most staff were aware of the safe processes associated with supporting people with complex needs. For example, we saw staff supporting a person who was expressing emotional distress, in such a way to reduce the risk of harm to themselves and others. Repositioning was not always completed or recorded as per schedules for people at high risk of poor skin or developing pressure sores. This placed them at risk of further pressure damage and was a safeguarding concern. We found no evidence that the late or missed repositioning had caused further damage to people’s skin conditions. When we brought these issues to the registered manager’s attention, actions were taken to mitigate risks. The registered manager and regional manager had identified there was a need for additional training in relation to dietary requirements, safeguarding and dementia awareness. During the assessment we saw some positive examples of staff demonstrating how they supported people safely.

Systems and processes to protect people from abuse and neglect were not effective enough, which increased the risk of immediate action not being taken in response to safeguarding concerns. The provider had a safeguarding policy in place and were aware of their responsibilities to keep people safe. There were on-going investigations in relation to staff members’ conduct. The registered manager and provider were liaising with the appropriate authorities. There was a whistleblowing hotline for staff to report any concerns they had. We reviewed safeguarding processes and found records of ongoing and recorded safeguarding incidents. These had been effectively managed and updated with outcomes and actions.

Relatives told us they were contacted following incidents occurring or new risks emerging. They told us they received information about changes to people’s support needs. Some relatives of people who lacked capacity told us they had been involved with DoLS applications and meetings. However, we saw that risk assessments were not always robust for some decision-specific needs. This meant the person remained at risk of harm of having restrictions in place which may not be the least restrictive option. For example, some people who lacked capacity had alarm mats in place but there was no evidence of any process to assess if this was in their best interest or the least restrictive option. Relatives told us they were not always involved in reviews of their loved ones’ needs. There were face to face meetings to involve people and their relatives. However, we were told by some relatives that they were not informed of the dates of such meetings, and this is why they did not attend. The registered manager told us they would look at options of making this process more inclusive.

Staff we spoke with were aware of risks to people and their role in monitoring and managing these. We saw there were some gaps in staff training, but the registered manager had identified some of these shortfalls and had training booked. However, this was not the case for staff training in hydration and repositioning people, where further training had not been booked. Staff told us how they supported people in a way to encourage independence whilst monitoring the associated risks.

We observed areas leading to the exit of the service were only accessible via key codes or fobs; this was due to people who were at high risk of leaving the service. People were supported to access the community, and we saw that safe staffing levels were in place to minimise risks to people.

Risks to people had not always been assessed with them or clear plans developed, with accompanying guidance for staff, for managing these. Some people's support plans lacked clear guidance for staff about their role in monitoring and providing a consistent approach. The system for involving people and relatives when assessing, managing and updating risks was not fully inclusive. We reviewed support plans and found a risk assessment had been produced in relation to most people’s known risks. However, we found shortfalls in this process in relation to significant risks such as self-harm and seizures. Documents which we reviewed evidenced that there was some improvement needed in the updating of support plans and risk assessments following contact with other health professionals to provide further guidance on how to manage risks for people using the service. There was not always evidence that decision-specific mental capacity assessments or best interest meetings had taken place when required, such as prior to the implementation of sensor mats for people lacking capacity to use the call bell. A matrix to monitor applications and outcomes for DoLS was in place and no one had any outstanding conditions other the standard conditions applied to their outcomes. There was a system in place to review and update care plans and risk assessments. However, these reviews were not always robust and did not identify the conflicting information or lack of timely updates which we found and discussed with the registered manager. The provider had a record in place to monitor when risk assessments were due to be reviewed. The registered manager told us they had a management checklist to be completed daily by senior team members to ensure all support needs were completed and the environment was clean and safe.

Most people and relatives told us they felt safe living at Lyndon Croft and had no concerns in relation to the environment being unsafe. However, one person told us at times they did not feel safe as other people came into their room. They told us, "My only concern is that other residents come in my room and sometimes make me feel unsafe. Staff do what they can and tell them not to." Most people told us if they raised concerns in relation to the environment they were actioned quickly. However, we found where furnishings had been requested several months earlier, these had still had not been provided.

There were no on-site maintenance staff working in the home which we were told by the registered manager, id cause a delay in repairs and maintenance at times. Managers demonstrated they wanted to ensure people were safe by the actions they had taken to monitor and reduce identified risks in the service. Staff were able to tell us what actions they would take if they found faulty or damaged equipment.

We observed some environmental risks during the assessment. We observed an unlabelled bottle in the dining room, which appeared to contain a cleaning agent. A staff member confirmed this was washing up liquid which had been decanted from the larger bottle. This placed people at risk from potentially drinking this liquid or splashing it into their eyes or on their skin which had the potential to cause harm. We observed staff bags, coats and personal food items were left in communal areas which could be accessed by people living at the service. This placed people at risk. Storerooms were always locked to ensure people could not access items such as cleaning products. Cleaning trollies containing potentially harmful substances were within sight of the housekeeping staff when cleaning rooms. Keypads were used to restrict access to high risk areas of the service.

Data sheets to guide staff on actions to take should cleaning products or chemicals be swallowed or come into contact with people’s eyes or skin were stored in the registered manager's office and not where these products were stored or used such as the kitchen, laundry and COSHH cleaning cupboards. This meant in the event of an incident staff needed to go to the office which could cause a delay in the correct treatment being administered. There was a system where staff recorded and reported areas requiring maintenance or equipment requiring repair which was then actioned by head office. Staff had failed to always follow correct processes in the management and safety of people and their environments. This meant people were at times exposed to risks. There were audits and checks carried out in line with health and safety guidelines, to ensure equipment was safe for use.

People and relatives told us they or their loved ones were normally supported by staff who knew them well and recognised risks. However, changes in staffing, at times, made them feel concerned that staff did not know people well. Many people and relatives told us that staffing levels at the weekends seemed to be a problem with less staff on duty than in the week. Some also raised concerns about staffing levels at night. This made them feel the service was less safe and resulted in them having to wait longer for support.

Most staff felt they had enough training, information and support to support people safely. Some staff told us they would prefer more face to face training. Others raised concerns with the length of some training courses, which they are expected to complete in their own time. Following the assessment the regional manager told us how this has been taken on board by the provider and how training was delivered was currently being reviewed. Once online learning was completed there were no checks or discussions completed or observations recorded to evidence staff learning and implementation of their learning. The registered manager told us staffing levels were adjusted according to people's needs. However, many staff told us they felt the staffing levels were too low to spend meaningful time with people. Some staff also told us how at weekends and night the staffing levels were of concern, and they felt they were not always able to support people in a timely way.

We observed that staffing ratios appeared to be adequate to meet people’s assessed needs during our time at Lyndon Croft. Staff were available to support people when they needed support or guidance. Most staff knew people well. This was demonstrated by the positive interactions and responding to their requests. We observed appropriate staffing levels being maintained during the days we visited the service. The layout of the building did not lend itself to staff being able to maintain line of sight with people due to the branching of corridors causing blind spots. This increased the risks to people at high risk of falls. The manager was aware of this and where possible, moved people at high risk to more visible rooms. For people who were unable to leave their room or chose to stay in their rooms and did not have call bells, 60 minute observations had been implemented and additional pressure alarms to alert staff.

The provider had not always ensured staff had completed all the training they needed. The provider’s staff training record indicated staff received regular training in many areas, but there were gaps which needed to be addressed. The registered manager assured us they were addressing these shortfalls, and we saw evidence of training which was scheduled to take place. Competency assessments were carried out for some areas of training. The provide also had ‘60 second’ training which staff read and had the opportunity to discuss as a group. Feedback from staff about the ‘60 second’ training was positive. Staff files did not always evidence that staff members’ inductions were robust and that suitable references had been obtained or risk assessments implemented. The registered manager used a dependency tool to ensure staffing levels were safe and a rota system was in place. Although there were gaps in the rota at times, the registered manager and regional manager assured us the staff numbers were in line with the dependency tool and numbers of people living at the service, at that time.

People and relatives told us they found the home to be clean and tidy and they were happy with the standards of hygiene. One person told us how the carpets had been removed and new flooring laid, which had made a big difference.

Housekeeping staff were provided by an external agency and provided daily cleaning of the service. Outside of these times it was staff members’ responsibility to clean the service. Most staff had received infection prevention and control (IPC) training. Some staff told us they felt they did not have time to carryout cleaning duties when supporting service users. This was a particular concern at night with lower staffing levels and having cleaning responsibilities. Not all staff could tell us about the safe practices for holding or chilling of hot food or reheating. This placed people at increased risk from food poisoning. The registered manager told us this would be addressed with staff and measures put in place to keep people safe.

We observed most areas of the service were clean and tidy, including bathrooms and equipment. However, some areas such as the kitchen area in the dining room needed more robust cleaning, such as radiators and windowsills. Some personal protective equipment (PPE) stations were not adequately stocked, hand sanitiser and gloves were not always available. We found some items of food which did not have a date of opening recorded to ensure they were not used past the recommended date after opening. We observed food such as cakes and biscuits stored in a cardboard box under a table in the dining room. This increased the risk of cross contamination. This was addressed immediately by the registered manager. We also observed cupboards in 1 kitchen area where the wood had become exposed meaning it could harbour germs and not be effectively cleaned. This has not been identified on the recent environment audit for repair or replacement. We also saw plastic cups which had become scored and stained were in use. These had become porous and could not be thoroughly cleaned. The registered manager told us these would be reported to head office for action. We observed staff following good practice in the correct use and disposal of PPE. New chairs had been purchased which had wipeable coverings to help aid infection control and cleaning of the furniture.

There was a policy and procedure in place for infection prevention and control (IPC). There was a daily walkabout carried out by the managers which included checking staff members’ IPC practices. IPC audits were carried out monthly to ensure standards of good practice were upheld. It was positive to see that these identified areas of improvements, however, these did not identify all of the areas of concern we observed. The local authority IPC team carried out an IPC visit within the last 12 months and rated the service good.

People and relatives told us they did not have any concerns in relation to their medicines administration. However, we identified some areas of concern in relation to safe administration and recording of medicines. We observed staff gain consent prior to administering medicines and talking people to offer reassurance. However, there was no handwashing between administration tasks which place people at risk from cross contamination.

Staff told us they had received training and competency assessments and felt confident in the administration of medicines. The registered manager told us there was now always a medication trained staff member on duty to ensure people received their medicines as prescribed. However, one staff member told us this was not always the case in relation to medicines which required two staff for the administration process, and some people had to wait for medicines which required 2 staff to administer. For example, they said a medicine which should be administered at 18.00hrs was often delayed until 20.00hrs. This meant this medicine was not always administered as prescribed. We found and were told by staff that at times there was a delay in repeat medicines being prescribed by the GP and supplied by the pharmacy. This meant at times people did not receive their prescribed medicines as prescribed although the service had been chasing the supply of these.

People were not always supported to receive their medicines safely. The provider had policies and procedures for safely managing medicines, however we found staff failed to always follow these. There was a lack of information for staff in relation to 'time specific' medicines or when certain food or drink should be avoided. Medication audits were carried out; however, these had not identified the potential 'inappropriate' use of some PRN medicines and 'missed' medicines when people were sleeping. The registered manager told us following our findings they had implemented a more robust medicines audit to capture our findings. Thickeners were also not clearly signed for when being used. This meant there was no supporting evidence that thickener was used each time fluids were provided, as per people’s assessed needs. Staff were not always following the correct administration guidance. For example, when a person missed several doses of medicines due to being asleep and there was no evidence this had been reviewed by the GP. Guidance for ‘as required’ (PRN) medicines was not always detailed enough with the signs to look for when people may require such medicines and PRN medicines were not always given as per the correct guidance. For example, 1 medicine used to help with anxiety, which the support plan stated should be used as a 'last resort' was given on several occasions when there was no supporting evidence to demonstrate the person had been unsettled. This meant we could not be assured such medicines were always used appropriately and as prescribed. Staff who applied people’s topical medicines did not always record these clearly. Clinical rooms were locked and clean and temperatures including the fridges were checked and recorded. All medicines we counted were all correct. We saw where a medication error had been identified swift action had been taken to seek advice. Care plans contained information about how people wanted to be supported to take their medicines.