Lindhurst Lodge Residential Home

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 aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk people could be harmed. The service was in breach of legal regulations in relation to the safety of the premises and infection control.

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.

The service 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. They made sure people were supported to express their needs and have a voice. The manager liaised with other professionals. This included carrying out pre-admission assessments before people moved to the home.

Staff planned and organised care and support with people, together with partners and relatives in ways that ensured continuity.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that.There were up to date policies and procedures in place for staff to recognise and respond to any allegations of abuse. Staff had received training in this area and understood how to keep people safe. In addition to keeping a record of all safeguarding concerns we saw the registered manager kept a record of any accidents and incidents that took place. These were described as not meeting the safeguarding threshold; however, we saw the cause and effect of each accident or incident was investigated. Similar incidents were linked together to identify any trends and common causes, and action plans were put in place to reduce the risk them happening again.

The provider assessed risk to ensure people were safe and well. Staff took action to mitigate any identified risks. Risk assessments were personalised and provided staff with guidance to follow. Staff showed an understanding of the risks people faced. We found risk assessments had been completed, specific to the individual, including, taking medicines, nutrition, breathing, moving and handling and pressure care.

At the last inspection people and their relatives commented that they wanted the provider to refurbish the home's environment, as some areas of the service looked tired and outdated. Whilst we acknowledge the registered manager had a refurbishment plan in place to gradually improve this, we found a number of concerns that needed addressing immediately during this assessment. The service failed to consistently detect and control potential risks in the care environment. Window restrictors were not fitted to all windows. This increased the risk to people who could fall out of windows. We found electrical wires trailing and stairs with open rise treads that could present a trip hazard to people. The service did not adequately protect people from the risk of fire. Personal emergency and evacuation plans (PEEP) were in place however the PEEP folder did not contain assessments for 4 people who were at the service. Moss-covered fire exits needed cleaning, potentially compromising safe evacuation during an emergency. The registered manager responded immediately during the inspection to address these issues. Several areas of the home appeared tired and required refurbishment and redecoration. Chipped paintwork, walls and door frames with holes needed refilling and repainting and ceiling tiles needed repair. The areas for improvement we identified during the site visit were not identified as part of the providers quality monitoring systems.

We observed that staff were busy but were able to meet people's individual needs within an acceptable timeframe. When people were asked to wait for staff assistance, the reason for this was explained to them, and staff were seen to prioritise tasks according to need. At the time of the assessment, there were vacancies for a team leader, an activities co-ordinator, and domestic staff. The shortage of domestic staff meant essential cleaning was not always completed as required. Staff also told us they had limited opportunities to support people with social interaction or activities to ensure they remained meaningfully occupied throughout the day. We discussed this with the registered manager, who told us they were in the process of recruiting to these posts. We recommend the provider consider alternative ways of deploying staff to ensure people receive adequate social interaction and support throughout the day. People were supported by staff who had the knowledge and skills necessary to carry out their roles in meeting people's needs. Staff were suitably trained and received regular supervisions. Staff were confident any concerns they raised would be taken seriously by the registered manager and responded to appropriately. Staff told us they worked well as a team and were happy in their roles. They had access to a variety of online training, had recently completed some face to face training and generally felt well supported. We looked at the recruitment information for 3 staff members. Records confirmed a range of checks including application, interview, and Disclosure and Barring Service (DBS) checks were conducted before staff started working at the service. However, we found gaps in recruitment records. For example, exploring gaps in employment and ensuring applicants completed paperwork in full. The registered manager was responsive to the concerns raised and immediate action was taken for the records identified and a review of other records was to be completed.

The service did not always assess or manage the risk of infection. While the people we spoke to said they were happy with the environment, our assessment found elements of care did not meet the expected standards. Not all areas within the home were well maintained to facilitate good infection and control procedures. Some areas of the home such as toilets were in a poor state of repair. This inhibited good cleaning practices and increased the risk of bacteria harbouring and infection spreading. There were several bathrooms in use. Across the bathrooms and toilets, we found equipment needed to be cleaned or repaired. For example, we found a dirty shower chair, soiled toilet seats and leaking toilets. Furniture was visibly stained and there were malodours in the home.

People confirmed they received their medicines in a timely and safe manner. People were supported by staff who followed systems and processes to administer, record and store medicines safely. Staff told us they received training and competency assessments to ensure they were safely administering medicines. Training records confirmed this. However, documentation required improvement. For example, some medication administration record (MAR) charts were handwritten and not always signed by another member of staff. Where people were prescribed variable doses, for instance one or two tablets’ records did not always show the quantity administered. The provider responded immediately during and after the inspection to address these concerns.