Lyles House

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• 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

Assessment findings demonstrated an overall deterioration in the standards of care service provided, with breaches of the regulations 12, 17 and 18 identified. Safe systems, pathways and transitions: We identified people assessed to be at risk of weight loss, choking, and constipation who staff had not referred for further assessment or advice on how to safely meet their needs. We identified that where people were experiencing falls urgent medical attention was not consistently sourced. Involving people to manage risk: Care records demonstrated a lack of recognition by the service to identify, review or manage risk. Documents including risk assessments were inaccurate and out of date. Safe environments: The care environment was poorly maintained and visibly unclean with the presence of malodor on both days of our assessment. Risk items were not stored securely to protect people from harm. Individual risks were not assessed. Safeguarding: People were not protected from harm or abuse and onward referrals were not being made. Safe and effective staffing: There were not enough trained and competent staff to meet people's needs, particularly at night. Medicines optimisation: People were not receiving their medicines as prescribed. Action taken to address risks , errors and poor practice were only addressed as an outcome of our assessment feedback.

This service scored 6 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People's daily lives were not improved as an outcome of incidents, as staff did not reflect or act on findings to improve standards of care provided. There was a lack of learning culture present within the staff and leadership team.

People were not supported to maintain their own safety due to a lack of provider level oversight of risk. Where people were experiencing falls and suffering possible head injuries the service had no post falls head injury monitoring systems in place to ensure their health and welfare was being monitored. We also identified examples of where urgent medical assistance was required and not sought. People assessed to be at risk of choking, weight loss and changes in their ability to safely use equipment had not consistently had onward referrals made by the service to external health and social care professionals. People's care records demonstrated a lack of involvement with people and their relatives to ensure their wishes and preferences were reflected in the care provided. People's care records were inaccurate and out of date. This increased the risk of people's individual needs to not be monitored by staff, including in relation to people's bowel and pressure care needs.

The provider and interim manager confirmed when asked that the required recording and oversight of people's care needs, in relation to the management of constipation, pressure care, individual health conditions such as epilepsy were not in place. The provider's own audits of care records identified information contained to be out of date, and for people's care records to be re-written.

The provider's policies, procedures and business continuity plan were not being followed by staff, and staff demonstrated a lack of awareness of required processes to follow to maintain people's safety. For example, where people's medicines were out of stock, staff were not following the provider's business continuity to plan that stipulated that staff should go and collect the required medicines by car to prevent people from missing prescribed medication.

Most people told us they were happy living at the service; however, some people told us they were unhappy living at the service and felt unsafe. People living with dementia were reliant on staff to keep them safe, and to recognise risks and protect them from harm.

Staff were not being protecting people from the risk of harm and abuse. We witnessed safeguarding concerns during the assessment visits. Staff demonstrated a total lack of understanding about how to keep people safe, and who to report concerns to. Due to a lack of provider level oversight, records relating to accidents/incidents/ safeguarding concerns were not being kept up to date and did not reflect if required reporting for example to the local authority and to the commission had been completed to safeguard people. This did not demonstrate an open and transparent approach to safeguarding within the service.

Staff demonstrated a lack of implementation of safeguarding training into their daily practice and approach. The provider and staff team were not following their safeguarding policies and procedures.

People were not supported to proactively manage risks. People were being placed at significant risk of harm, due to a lack of assessment and recognition of risks, particularly within the care environment. For example, no consideration of risk management for people using the stairs unsupervised, or where needing staff to support them to access stairlifts in place. This was of particular concern where people were known to be at risk of experiencing falls, yet the service had not considered whether a ground floor bedroom would be safer.

Staff and leaders demonstrated a lack of understanding of their responsibilities to support people to keep safe. Staff did not encourage people to take positive risk taking, in consultation with people, their relatives and external health and social care professionals.

We observed risk items such as denture cleaning tablets, prescribed creams and personal care products to be stored unsecurely in people's bedrooms, this increased the risk of people accessing items without required staff supervision. We found sensor mats to be unplugged, which did not ensure staff were alerted in the event people experienced falls for example during the night. We observed call bells to sound frequently throughout both assessment visits, with poor response times due to limited staff availability. Our findings were supported by the provider's own call bell audits which confirmed response times by staff to be poor.

Processes for the reviewing and updating of people's risk assessments were not being followed to ensure information was kept accurate and up to date. The provider had not put structures in place to ensure such tasks were delegated within the staff team. Where risks were identified in people's care records, risk mitigation plans were not followed to protect people from the risk of harm or injury. For example, a number of people had 'scalding risk assessment in place' outlining the need to keep the door to the kitchen closed when staff were out of the kitchen, to protect people from accessing hot surfaces and liquids. We repeatedly found the door to the kitchen to be held open without staff being present in the kitchen.

People were not living in a well maintained or clean environment, increasing the risk of the spread of infection. People's assessed needs and risks were not assessed in relation to the location of people's bedrooms, and access to corresponding shared facilities to maximise people's levels of independence and safety. Where people required the use of equipment for example to assist people to move from their bed to a chair, the suitability, safety and cleanliness of this equipment was not kept under review by staff.

We observed people to have unsupervised access to the laundry room, which also contained cleaning chemicals. We found equipment used with people such as commodes to be visibly unclean, and there was strong malodor throughout the service.

Provider level audits completed to check the condition and quality of the care environment, either were not reflective of the concerns and risks found during our assessment or, where actions were identified these had not been addressed. For example, the provider's health and safety audit identified when their gas safety certificate was due to expire, but no action had been taken to have this renewed. This remained outstanding when we completed our assessment visit.

People told us there was not enough staff on shift, resulting in delays in staff responding to their needs. We observed this to be compounded by a lack of shift structure and allocation of responsibilities within the staff team. People's individual preferences in relation to the gender of staff to support with personal care tasks was not able to be accommodated, particularly at nighttime. On the first day of assessment, both night staff members were male. People's medicine management needs were not consistently met, particularly if requiring medicines overnight, as there was a lack of medicines trained staff working at nighttime. The majority of people were assessed to require the assistance of 2 staff to support them to evacuate in the event of an emergency such as a fire. There were only ever 2 staff on shift overnight which could result in delays in supporting people to evacuate safely.

Training information shared by the provider demonstrated staff had not received training to meet the requirements of their roles and responsibilities. There was a lack of competency assessments in place to review implementation of training into staff practice. The provider was not proactively sourcing feedback and opinions from their staff team to influence change and improvement to the running of the service.

We observed staff interaction with people, and inspectors. We found staff to now always have a good understanding of English and had poor communication due to this. This impacted on how they communicated with people and resulted in poor outcomes for people. For example, we observed a person verbally expressing pain, and multiple staff walked past or interacted but did not question or recognise the person to be experiencing discomfort. This was only addressed when inspectors intervened and asked a staff member to support the person to access the toilet. We observed staff to have limited time available to spend with people, including where people required support with basic tasks such as eating and drinking. At times inspectors intervened to offer people support in the absence of staff. For example observed people to eat their lunch, including people at risk of choking, with no staff present in the dining room for long periods of time.

The provider's dependency assessment to determine required staffing levels was not found to be reflective of people's individual care and support needs. This resulted in insufficient numbers of staff being on shift, particularly overnight. From reviewing staffing rotas, these repeatedly showed a limited number of staff on each shift responsible for the completion of care tasks. Remaining staff were also responsible for the completion of cooking and cleaning, and aspects of maintenance due to the lack of a separate team responsible for these areas of daily routine. There was a lack of regular staff supervision and oversight of individual staff performance by the provider.

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

People told us they did not always receive their medicines as prescribed and some medicines were found to be out of stock, with a lack of action taken in response. This was found to be impactful for those people living with conditions such as constipation. People told us there were delays in getting medicines overnight due to a lack of medicines trained staff. This was of particular risk in relation to accessing pain relief. We observed people struggling to swallow prescribed medicines, this has not been discussed by staff with the GP to source an alternative. Where people were unable to verbally express experiencing pain, staff did not use a recognised pain assessment tool to assist them in assessing their needs. Some people were prescribed as required (PRN) medicines, however, there was a lack of guidance in place to support staff in recognising when this needed to be administered.

The provider was not completed regular medicines management audits to maintain safe practices within the service. We found people's medicine administration records to be altered with stickers placed over signature boxes, this made it unclear if medicines had been given as prescribed. The provider was not ensuring their staff were trained and competent to give people their medicines, where errors occurred provider level oversight of individual staff performance was poor. Staff were not following the provider's medicines management policies and procedures. For example, we found excessive amounts of medicines needing to be returned to the pharmacy and not accounted for. There was a lack of suitable storage arrangements in place for people's prescribed creams and skin care products.