Archived: Lyme Valley House Residential Care 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 inspection we rated this key question Requires Improvement. At this inspection we found there had been no improvements made. People's risks were not managed or mitigated to protect them from the risk of harm. Staff did not always have up to date information to follow to ensure they were aware of people's current risks. Staff had not always received the training required to keep people safe. There were not enough suitably recruited staff available to meet people's needs. The provider failed to manage people's risks safely. Medicines were not managed safely. The provider did not always learn lessons when things had gone wrong and learning from safeguarding investigations, accidents and incidents was not always shared with staff. People were at risk of harm because the provider had not ensured building and environmental checks had been completed as required to make sure people were safe from the risk of harm. People were not protected from infection risks. During our assessment of this key question, we found concerns around the management of people's risks, the provider had failed to ensure the physical environment was safe for people to live in and people were not protected from the risks associated with infection. This resulted in a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can find more details of our concerns in the evidence category findings below.

This service scored 47 (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 did not always learn lessons when things had gone wrong. There were systems in place to identify when things went wrong. However, learning from safeguarding investigations and accidents and incidents was not always shared with staff. For example, although staff told us handovers and team meetings took place, discussions about learning from incidents were not recorded. This meant the provider could not be assured staff were learning effectively from incidents to ensure risk was being reduced or removed.

Staff told us there were systems in place to identify and act on safety concerns. The staff we spoke to told us they had attended daily handovers, team meetings and one to one meetings with the manager where they could discuss people’s changing needs and staff training. Staff felt they could raise any concerns with the approachable management team and they would address them. One staff member told us, “When a staff member did not care for people properly or treat them with respect, they were dismissed straight away.” Another staff member told us, “When a resident had a fall recently, I told my manager and reported it to the local authority safeguarding team.” However, we found learning from safeguarding investigations and accidents and incidents was not always shared with staff.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

Assistive technology was not always in place where required. For example, one person was assessed to require a sensor mat in their bedroom to reduce the risk of falling however this was not in place. This meant the person's risk had not been mitigated and they were at risk of harm. We saw staff supporting people to transfer safely using mobility equipment and explaining what they were doing.

Staff were not always kept up to date with people’s risks. Although systems were in place for staff to share information about people’s risks such as handovers and team meetings, staff were not always aware of people’s current risks. One staff member told us, “One person struggles with swallowing their medication but I don’t know if their medication has been changed.” Another staff member told us they were not aware one person required cream applying for their skin condition. The owner of the care home told us care plans needed improvements and the manager was in the process of reviewing them.

People's risks were not managed in a safe way. Where people's behaviours, including inappropriate sexual behaviour, put other people at risk, care plans did not include risk assessments to guide staff on how to manage these risks. This meant people and visitors were at increased risk of experiencing harm. Care plans for people at risk from skin problems did not include information about their risks or how to guide staff on how to manage these risks. One staff member told us they were not aware of what medication one person was prescribed to manage their skin risks. This meant people were at risk from having their skin needs met. Although care records identified one person had lost a significant amount of weight and had been declining food, staff had not made contact with health agencies. This meant people were at risk of malnutrition. Where one person, who lacked capacity to leave the care home independently, had left the premises via an unlocked side gate, their care plan was not updated to include the risk of absconding or guidance on how staff should manage this risk. This meant people were at risk from absconding.

People were not always supported with their risks. We received mixed feedback from people and their relatives about how people were supported to manage their risks. For example, one person told us, “Staff are supposed to support me daily with [a health need] however this does not always happen.” One relative told us, “We discussed our [relative’s] needs with the care home before moving in and we feel they are safe living here.”

People were not protected from the risk of fire. Recommendations made in the care home fire risk assessment about how to ensure the building was safe from the risk of fire and reviewing evacuation procedures had not been followed up. This meant people were at risk in the event of a fire. Although there were call bell audits taking place, these did not identify missing call bell cords in people’s bedrooms. This meant people with high mobility needs were at risk of not being able to request support when needed.

We received mixed feedback from staff about how safety concerns about the environment were managed. One staff member told us, “The management are aware of concerns about building safety but don’t want to spend money on fixing them.” Another staff member told us, “The maintenance book is completed and I tell the maintenance staff member who addresses things. When one person pulled a railing off the wall, they were supported to the right environment and were kept safe.” Staff told us they were not confident they could evacuate people safely in the event of a fire. The provider told us they could not evidence issues from the last fire risk assessment had been resolved.

People were at the risk of harm as the provider failed to ensure the physical environment was safe for people to live in. People were not protected from the risk of fire. There were holes in a ceiling and a wall above 2 fire doors. A side gate in the courtyard was secured with a padlock which did not meet fire safety recommendations outlined in the care home’s fire risk assessment. This meant people were at risk from the spread of fire. People were not fully protected from the risk of falls from height. Window restrictors were not installed with tamper proof fixings which meant they could be removed with simple tools such as a knife. A storage room on the first floor, leading to the boiler, contained substances hazardous to health and had been left unlocked. This meant people were at risk of harm from accidental or intentional ingestion. A second unlocked storage room and a toilet room on the first floor contained hot pipe work to radiators which had not been covered. This meant people were at risk from scalds and burns. A sensor mat had been plugged into the wall adjacent to a fire exit on the first floor. Flooring on both floors of the care home had been damaged. People’s bedrooms contained trailing cables from electrical items. The ground conservatory had a ramp at the entrance which had lifted and a wooden panel was located under tables where people could sit. This meant service users were at risk of trips and falls and not being able to evacuate safely in the event of a fire.

Staff gave mixed feedback about management supporting them to deliver safe and effective care. One staff member told us, “I have been working here a while however I still haven’t had any safeguarding training.” Another staff member told, “I am doing an NVQ and the manager is helping me to get more training.” The chef told us they had not completed any training about modified diets and they were expected to cater for people on modified diets. When we asked the owner about this, they could not evidence there was a plan to provide training about modified diets. All the staff members we spoke to were able to tell us how to keep people safe and to report safeguarding concerns.

The provider did not ensure there were sufficient numbers of suitable staff. The care home’s fire risk assessment had recommended a review of staffing numbers to ensure realistic evacuation times however this was not done. This meant the provider could not be assured there were enough staff available to evacuate people safely in the event of a fire. Staff had not always received the required training to deliver safe care. For example, the owner told us agency staff covering nights had not had fire evacuation training. Some permanent staff members had not received their annual refresher training including fire safety, medication, safeguarding, mental capacity, and moving and handling. The provider could not evidence staff had always been recruited safely. We found some staff files did not include Disclosure and Barring Service (DBS) checks, references or full employment histories.

We were not assured that the provider was promoting safety through the layout and hygiene practices of the premises. One relative told us, “The environment has been steadily deteriorating since [relative] has been here and it’s a challenge for the owner to make improvements.” Another relative told us, “The environment is very tired now and needs a lot of improvements.”

People were not always protected from the risk of infection as staff were not consistently following safe infection prevention and control practices. The provider was advertising for another domestic worker due to a staff shortage. At the time of our inspection, the domestic staff member was on leave and care workers were responsible for completing cleaning tasks. Although staff had discussed cleaning tasks in the daily handover, they had not seen the cleaning schedules and therefore could not be sure what cleaning tasks required completion. Completion of cleaning tasks for bedroom and communal toilet rooms were recorded daily however there were several occasions where cleaning tasks had not been recorded as having been completed. This meant that cleaning could not be carried out effectively and service users were at risk from infection.

We were not assured that the provider was promoting safety through the layout and hygiene practices of the premises. We found cracks and scuffs on walls, damaged paintwork on a mobility rail and damaged woodwork on a fire door. We found damaged and unclean flooring in a communal toilet on the 1st floor and damage to wallpaper. This meant that cleaning could not be carried out effectively and service users were at risk from infection.

People were not always protected from the risk of infection as staff were not consistently following safe infection prevention and control practices. Staff told us they complete cleaning tasks when the domestic staff are off. However, when we asked staff what cleaning schedules they were following they could not locate cleaning records. One staff member told us, “It's an old building and needs modernising.” Another staff member told us, “I’ve had training to use infection prevention control products.

People were not supported to receive their medicines in a safe way. Some opened liquid medications which included information about how long they could be used for, had not been labelled with the date they were opened. For example, we found liquid Folic Acid medication (used to treat low levels of vitamin B9), liquid Paracetamol (used to treat pain) and liquid Lactulose (used to treat symptoms of constipation) were being administered to people without staff knowing when they had been opened. This meant are risk of not receiving their medication safely. Care plans did not always include accurate information about people’s medicines. For example where people required cream medication to manage their skin condition, this was information was not recorded in their care plan. Staff administering medicines to people had received training. However, records showed this training had not always been refreshed when required. This meant people were at an increased risk of harm through poor administration of their medicines. Medicine Administration Records (MAR) were completed. Although we found several gaps in historic records, the provider had made improvements in the recording of when medication was administered. There was an up-to-date medicines policy in place.

People did not always receive their medications as prescribed. One person told us, “Staff are supposed to support me daily with my medication however this does not always happen.” When we asked staff what medication the person was prescribed, they were unable to tell us.

Medicines were not always managed safely. Staff told us people did not always swallow their medication. One staff member told us, “One of the residents chews their tablets and doesn’t swallow them but I don’t know if this has been referred to the GP.” Another person had been identified as chewing and not swallowing their medication and was referred to the GP however when we asked the owner, they could not find any record of the outcome. Although the person was not currently prescribed medication which could be chewed and staff told us the GP would prescribe liquid medication in future, this information was not recorded anywhere. This meant the provider could not be assured people were receiving their medication safely.