Lee Mount 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 remained good.

This meant people were safe and protected from avoidable harm.

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.

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

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.

Systems were in place to make sure people were safe and received the support they needed. Robust investigations took place of any potential safeguarding issue, and we saw examples of actions taken to make sure the issue did not reoccur. Referrals to the local authority safeguarding team were made as needed and the management team took time to follow up on these. Managers completed a monthly analysis of all safeguarding events and discussed their findings with staff to share learning.

People’s relatives told us they were confident their loved ones were safe at the home.

Staff had received safeguarding training and knew what to do if they had concerns about a person’s safety or wellbeing and said they would report any concerns. They told us about the importance of using time providing personal care support to check for any concerns. One staff member said, “We have to inform about every resident if we have any concerns, it’s better to report something and it not be a problem, than not report something that is.”

Where Deprivation of Liberty Safeguards (DoLS) were in place, these were managed well and systems were in place to evidence how any requirements of the DoLS, known as conditions, were being met. People’s capacity to make decisions about their care was assessed and where they lacked capacity, records were in place to show how the best interest decision process had been followed.

Staff provided care that was safe, supportive and enabled people to do the things that mattered to them. Where risks to people’s health and safety had been identified, a risk assessment had been put in place. Risk assessments were regularly reviewed and clearly outlined the potential risk to the person and the support staff needed to provide to minimise the risk. Although relatives told us they were involved in the assessment process, this was not always evidenced in the documentation. The registered manager introduced new documentation during the inspection to address this.

Staff were familiar with people’s risk assessments. They told us how they supported people who became anxious or distressed to lessen the risk to themselves or others. Staff noted that following the increase in activities provision there had been a noticeable reduction in distressed behaviours because people were often kept occupied.

People’s relatives told us a strong staff presence assured them that risks to their loved one’s safety were minimised.

Effective arrangements were in place to monitor the safety and upkeep of the premises. Professional safety checks on the environment and equipment were up to date and internal auditing was carried out routinely.

Staff told us that the service’s in-house moving and handling training included how to check equipment prior to use and how to use it safely. They had no concerns in relation to the equipment they used.

Plans were in place and were being discussed with people who lived at the home and their relatives, to refurbish several areas of the home. The registered managers told us how the refurbishments would add to the safety of the environment and assistive technology would be used to support this.

A person who lived at the home told us they, “Felt very safe here.” They said they could lock their room door if they wished, and all the staff were very respectful of their personal space.

Robust safe recruitment practices were in place to ensure staff were competent and confident to carry out their roles.

Staff told us they believed staffing levels were appropriate and that a good mix of skills across teams meant they were able to effectively meet people’s needs.

All the feedback we received about staffing levels was very positive. One person told us there were always staff around to help or chat with them. They said the owner provider and managers were part of the team.

Staff were up to date with training. They told us the training supported them in their roles, in a variety of ways that catered for different learning styles. They told us they were encouraged to consider any additional training they would like to undertake and that this was approved. An example was given of a staff member with an interest in end of life (EOL) care who was supported to attend a specialist course with the local hospice, with a view to becoming EOL champion.

On the first day of our inspection, we identified areas where more robust cleaning was needed. The registered manager took immediate action to address this.

Staff understood about infection control, and we observed this in practice.

One person told us they were, “Very pleased with how clean everywhere in the home was.” They said the cleaning staff attended to their room daily and they had no complaints about how they did their work.

A relative said they visited weekly and always thought the home was kept very clean.

Medicines were managed and administered safely overall although we identified some areas where improvements to the systems in place would be beneficial.

For example, medication administration records (MAR’s) should show the times of administration of medicines prescribed to be taken at specific times and the recording of where patches for pain relief were positioned should be more detailed.

Protocols were in place for medicines given prescribed on an ‘as needed’ basis, but these did not include a space to record if the medicine had been effective. Allergies to medicines and likely components of medicines also needed to be recorded on the MAR.

We were assured by the registered managers that all of the above would be addressed without delay.

Prior to this inspection, CQC had received a concern that medicines were being given to sedate people unnecessarily. We found no evidence of this. Where this type of medicine had been prescribed for a person in response to an emergency, staff requested and completed a medical review of this as soon as possible as they were concerned about the sedating effect.

We received feedback from partners about a person who had moved to Lee Mount from another service because of presenting with behaviours that challenged. Staff’s support to engage this person in meaningful activities had resulted in them no longer needing medication to manage their anxiety and resulting behaviours.

People received their medicines when they needed them. One person told us they had cream applied and the staff were always very gentle when they did this. They said, “I never have to remind them that it is due.”