Archived: Lyme Valley House Residential Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last inspection we rated this key question Requires Improvement. At this inspection we found there had been no improvement made. The provider did not have effective environmental safety systems in place to ensure people were safe from the environmental risks. The provider did not have effective quality monitoring systems to ensure people received safe care. The provider did not have effective systems in place to ensure there were enough suitably trained staff. The provider did not have effective systems in place to ensure continuous learning took place. At our last inspection the provider had failed to establish systems to effectively assess, monitor and improve the quality and safety of the service. This was a breach of regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. During our assessment of this key question, we found the provider had not made enough improvements to the oversight of the service, which resulted in a continued breach of Regulation 17 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 46 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider failed to maintain oversight of their fire risk assessment, safety checks and audits to ensure they were being carried out appropriately to identify safety concerns and where faults or concerns had been identified, corrective action was taken. For example, we found defects to the décor and health and safety concerns had not been identified by environmental audits. The provider failed to maintain adequate systems to monitor and mitigate risks to people regarding infection prevention control procedures, call bell audits and consent to care to ensure people were protected from the risk of harm. For example, we found several call bell units in people’s rooms were missing pull chords. This meant the provider could not be assured people could request support when needed. The provider failed to maintain oversight of medication administration procedures to ensure service users received their medication safely. For example, checks had not identified liquid medications did not contain labels to indicate when they had been opened and their used by dates, which placed people at risk of receiving ineffective medicine. Care plan audits had not been carried out to ensure people’s needs were up to date and accurate. People were not always referred to the relevant health agencies when required, which meant their was a risk people's health needs would not be met. There were no systems in place to ensure staff were suitably trained and recruited safely to protect people from the risk of harm. There were no systems in place to ensure learning from incidents was shared with staff to make improvements. Investigations had taken place when things went wrong, however, the provider could not evidence how learning took place. This meant the provider could not be assured risks were mitigated. The provider failed to ensure there were systems in place to obtain feedback from service users, relatives and staff to inform improvements at the service.

Although the provider told us the environment needed improvements and there was a plan to renovate bedrooms and communal areas, they could not provide us with evidence of the plan. The provider told us they had switched to an electronic system as employment records had been poor and records had been going missing. However, when we asked about some recent employment records, they could not locate them.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.