Lee Gordon 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 that 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 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and relatives spoke positively about the manager and the service provided. One relative said, “The manager is very approachable, and I have absolutely no concerns. I am involved in [Person]’s care and kept up to date."

Staff told us they enjoyed working at the service and were positive about the improvements the new manager had made. Staff felt supported and able to raise any concerns with the manager and were confident action would be taken. Staff received training suitable to their role to meet people’s needs safely and demonstrated an understanding of how to monitor a person’s health and the importance of reporting any changes to the appropriate healthcare professional. One staff member told us, “There is lots of guidance in place about how to support each person."

We identified some environmental concerns, for example the cleanliness of the bathrooms and some equipment. We brought this to the attention of the manager who took action to address this during the assessment. The provider had recognised improvements were needed and the management team were open and honest about the issues the service had recently faced, and an action plan was in place to drive forward these improvements. However, further time was needed to ensure these processes are fully embedded and sustained. Staff recorded accidents and incidents, and these were reviewed by the management team to identify any trends or patterns so actions could be taken to mitigate emerging risks. Any lessons learnt were discussed in team meetings.

Relatives told us staff promoted their loved one’s health and wellbeing. One relative told us, “I would say [Person] is fantastic. I have never seen such a change in a person in such a short space of time. They have changed beyond all recognition. It’s simply wonderful."

Staff worked in partnership with other health and social care professionals such as GP’s, district nurses and social workers. This supported people’s health and wellbeing.

Feedback shared from health and social care professionals was positive. They told us communication with the service was good and confirmed the service followed their advice to ensure people’s health needs were monitored.

Processes were in place to ensure people were supported by a consistent team of staff. Staff knew people well and demonstrated a good understanding of people’s needs, working closely with health and social care professionals to ensure the person achieved good outcomes.

People felt safe with the staff who supported them. Relatives were confident their loved ones were safe living at the service and knew how to raise concerns if they had any.

Staff understood their responsibilities to keep people safe. One staff member said, “If I saw or heard anything I would go to the manager. Like if another staff shouted at the people who lived here or something like that. I know they wouldn’t but it’s an example. I can report it to the local authority as well". The manager had made appropriate alerts to the Local Authority (LA) and Care Quality Commission (CQC).

Care records viewed during our assessment informed staff if people had capacity to make day to day decisions for themselves. The manager had processes in place to record any legal authorisations in place to deprive a person of their liberty, called the Deprivation of Liberty Safeguards (DoLS). Any conditions related to DoLS authorisations were being met by the service. Staff were up to date with their safeguarding training and the manager had a process in place to monitor staff training. The management team understood their responsibility to report any concerns to the LA and to CQC to ensure any allegations or suspected abuse were investigated. There was a safeguarding policy in place to provide guidance for staff on how to report any concerns.

People were supported by staff to understand and manage risks. Relatives told us staff knew their loved ones well and managed any risks associated with their care. One relative told us, “Staff are very alert and observant without being intrusive which is reassuring”. Another relative said, “Staff are fully aware of the risk of aspiration when [Person] eats and they follow all the guidance in place."

Staff spoken with understood the risks associated with people’s care. For example, staff described how a person was at risk of choking and needed a prescribed thickening agent added to their drinks and a soft diet. One staff member told us, “Everything you need to know is on the DSP (electronic record). They are updated all the time, so you know what’s changed. The information is there for staff to follow that’s how we keep people safe."

During our visit we observed staff supporting people safely and in line with their care plan to manage risks safely. For example, people were encouraged to slow down while eating their meals and when walking around the home using their frame.

Risk assessments were in place to inform staff how to provide safe care and were regularly reviewed alongside the multidisciplinary team (MDT). Where appropriate care plans had documented agreements in place with the person to help monitor and reduce the risk of potential harm. Daily care records demonstrated people were supported to monitor their health and wellbeing, any changes were reported to the appropriate professional to ensure any risks and concerns were not missed and people continued to achieve good outcomes.

Relatives told us the service provided their family members with a safe, homely environment however, we identified some areas which required immediate attention. For example, external fire doors had plastic latches fitted, which required the latch to be pushed up before the emergency exit door could be opened. This posed risks of delays in exiting the home in an emergency. The manager responded immediately during the assessment to address this concern.

Staff demonstrated a good understanding of the action they needed to take to keep people safe in the event of a fire. One staff member said, “We have fire drills, and the fire alarm is tested, so we know what to do, if we were to have a fire."

We identified some potential risks on our arrival for example, 2 bedroom doors had been wedged open posing a fire risk and the laundry door was not locked, which contained hazardous cleaning materials. The manager took action to address these shortfalls during the inspection.

Environmental risks were not always well managed, as some control measures to mitigate the risk were not always followed by staff. For example, fire doors being wedged open and a patio door being left unlocked which left people at risk of potential harm, as people could leave or enter the home undetected. We raised these concerns to the manager who took immediate action to address these shortfalls. Regular maintenance checks are completed on the equipment in use at the service to ensure it is safe and in good working order. Records held information on how to report any faults with the equipment to either the manufacturer or relevant healthcare professional so they could be resolved promptly.

People told us staff were nice and took them out shopping and dancing. One relative said, “[Person] has a really good rapport with the staff, they have become their friends. The staff are amazing people."

Staff told us they received training and support appropriate for their role. One staff member told us, “The manager and deputy are very approachable. They are always about and willing to help or answer a question or explain how to do something”. Another said, “Things are really good here, I have learnt so much, it’s a good place to be."

During our visit we observed staff engaging with people in a friendly and caring manner. Staff were available when people needed them and people's requests for assistance were responded to promptly.

Rotas demonstrated staffing levels were maintained and people were being supported by a consistent staff team. Staff were recruited safely. The provider sought references and completed DBS checks. Disclosure and Barring Service (DBS) checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. Records viewed showed staff were up to date with their training.

While no-one raised any concerns to us regarding infection prevention and control (IPC), we identified concerns around the cleanliness of some areas of the home. People were accessing bathrooms which were dirty, with strong odours. The management team took action to address these shortfalls during the assessment.

The manager and area manager accepted our feedback about the need to improve IPC and standard of cleanliness within the home. The area manager gave assurance they would arrange a deep clean by an external company. Stating, “This will give the staff a good starting point". Staff had completed infection control training and demonstrated an understanding of how to reduce the risks of infection. Staff told us, “We have plenty of gloves and aprons. We also have face masks. We don’t have to wear the masks but if we have a cold or feel a bit unwell it’s best to wear them to keep them (People) safe."

Improvements were needed to some areas of the home to ensure they were clean and hygienic, as some shower curtains and aids were dirty. In contrast, other areas of the home had recently been decorated and appeared homely and comfortable. During our visit we observed staff using personal protective equipment (PPE) appropriately.

Daily cleaning records showed cleaning had been undertaken. However, our observations during our visit showed the cleaning itself was not always effective. The manager accepted our feedback and said, “This had not been a priority area for improvement but would ensure it was addressed." The provider had an IPC policy in place.

Relatives were confident their family members received their medicines as prescribed. One relative told us, “[Person] gets their medication, no problem.” Another relative commented, “They [staff] follow the instructions."

Staff spoke positively about the training they received to enable them to administer people’s prescribed medicines safely. The management team regularly observed staff practices to ensure they put their training into practice. However, staff did not always follow the provider medicine administration procedure. For example, prescribed food and fluid thickener were not safely stored. The manager responded immediately during the assessment to address this concern.

People’s care records did not always provide staff and other agencies with the information they needed to manage people’s medicines safely. One person’s discontinued medicine had not been removed from the person’s medicine support plan. The management team had not always ensured the providers policies and procedures were followed. For example, there was no facility to safely store prescribed items requiring refrigeration. The manager took action to address these shortfalls during the assessment. People had regular reviews of their medicines to ensure they were prescribed the most effective medicines to support their health and wellbeing. Records showed staff had received medicines training and their competencies were regularly checked.