Lynhales Hall Nursing 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- we rated this key question as good. People received safe care and treatment from staff who understood their healthcare needs and followed healthcare guidance from professionals. Where we had identified issues with the cleanliness of the service and also with the deployment of staff, the provider had responded by recruiting additional staff and also reviewing how staff were assigned to support people. A follow up virtual tour of the service and a review of information showed improvements had been made to how people were supported and the cleanliness of the environment. The provider ensured people were safe and received care which met their individual needs, protected their rights and safeguarded them from abuse and neglect. Medicines were managed safely by competent staff.

This service scored 75 (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 their relatives told us they could tell staff and management about things that concerned them. Some relatives told us when concerns around cleanliness were raised management had been slow to take appropriate action. We found when we raised issues around cleanliness of the environment and also around staff deployment the provider had identified the actions they needed to take to improve, and made the necessary changes.

Staff reported any accidents, incidents or concerns to the management team and these were reviewed and actioned appropriately to reduce the risk of recurrence.

The systems and processes enabled monitoring of accidents and incidents. Systems were designed to encourage reflective practice and lessons learnt.

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.

People told us they felt safe in the service. One person said, "It's fine [living here], I've got no problems. I do feel safe." Another person told us, "I feel safe and secure, never been mistreated."

Leaders understood their responsibilities to keep people safe. The registered manager demonstrated a good understanding of how to notify the CQC and the Local Authority about safeguarding concerns. Staff told us they would be confident to escalate safeguarding concerns internally, the local authority and to CQC.

We observed that staff were kind and attentive and providing care in a non discriminatory way when spending time with people.

There were comprehensive safeguarding systems, policies and procedures that considered the protection of human rights and supporting people to be protected from abuse, neglect and discrimination.

People had detailed and comprehensive risk assessments which were reviewed regularly. Risk assessments detailed actions needed to reduce risk. People and their relatives told us they were able to discuss and contribute to their risk assessments and care plans.

The registered manager supported staff to take action to reduce risk to people. For example, where a concern had been raised about the seating position for a person at mealtimes, the manager had discussed it at a staff meeting and actions taken to change the seating position to one which improved the mealtime posture for the person. This meant the person was less likely to choke on their food.

During the visit on 23 April 2024 we saw some people were supported by staff, however other people did not have the levels of support to keep them safe. For example, some people's support did not match what was written in their risk assessments. The registered manager told us they would take immediate action to ensure support matched people's needs. We carried out a review of the actions taken following our feedback and found the staff rotas and actions had been reviewed and improved.

There were comprehensive systems to assess risk and to ensure risk assessments were updated. The providers systems and processes encouraged reflective practice and ensured the management of risk.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe and effective staffing during this assessment. The score for this quality statement is based on the previous rating for Safe.

People’s experience of infection prevention and control (IPC) was mixed. For example, one relative told us they had mentioned to the staff that there was dried food on the wall but that it had not been cleaned off. "I've raised it many times," they said. "The carpets are in a terrible state, it's been really dirty in the past six months." One person said, “There are no problems here.” with another relative said, “I do not feel there is an infection risk here.”

The registered manager told us they had some keep housekeeping staff leave recently and this had impacted on the cleanliness of the service. During the site visit we saw some of the care staff undertaking cleaning duties, but areas of the home remained unclean until we identified this to staff and to the registered manager. Following our feedback during the site visit, the registered manager and provider took steps to recruit additional housekeeping staff and also review the frequency and quality of the cleaning in the service. They also ensured more frequent spot checks and walk around the home environment.

During the site visit on 23 April 2024 we saw areas of the service that were unclean and also that care was not always taken to ensure people were kept clean. A follow up virtual visit on 17 June 2024, demonstrated that the updated cleaning schedules, additional staff and the improvement in the manager oversight of infection control had a positive impact on the cleanliness of the service. We were assured that actions had been taken to ensure that the concerns we had on our site visit had been resolved.

The provider had an infection prevention and control (IPC) improvement plan which included an action plan that was aligned to their IPC policies and procedures. However, this was not effective at the time of our first visit as longstanding cleanliness concerns had not been identified or rectified. Following our feedback regarding IPC, this was included in the agenda for staff meetings and senior staff had increased the regularity of workarounds and spot checks.

We observed that staff took time with people when supporting them to take their medicines.

Only staff who had completed medication training were able to administer medicines. Nurses were able to tell us about people’s medicines needs, including where ‘as required’ (PRN) medicines were prescribed for specific health conditions such as epilepsy.

The provider had detailed medication policies and procedures. There were processes for ensuring that any changes to a person’s medications following a clinical appointment were documented in the ‘records of visiting healthcare professionals.’ However some of the changes to people’s MAR charts were not always clear. We raised this during our assessment with the manager. The manager took actions to improve how medication changes were recorded and we saw evidence to demonstrate this.