Lyndon Croft

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

The provider’s governance and quality assurance systems were not sufficiently effective to ensure the delivery of good quality care and support. Audits and checks completed had not enabled them to identify and address several concerns we found during this assessment. These included shortfalls in the assessment and management of risks to people. This included a lack of clear information and guidance for staff in people’s care plans and risk assessments following changes. This was a breach of Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Staff and management were clear about their individual roles and responsibilities, including the application of the MCA, DoLS and best interest decisions. Most staff told us they felt well-supported by management and felt confident about speaking up at work. The registered manager and regional manager had developed and action plan and were working to drive improvements in the service. They had actioned some areas of concern which we brought to their attention during the assessment but this a part of a larger piece of work.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Most staff supported the management approach to drive improvements for people using the service. Staff and management told us they understood the importance of listening to the views of people and their relatives of the service. Most staff told us they felt involved and listened to in relation to improving the service. Some staff felt communication could be improved but said it was much better than it had been previously. Feedback from staff was positive overall and most felt the direction and culture within the service was driving improvement. The provider told us they were committed to an inclusive culture for all. The registered manager adopted a transparent approach and shared their findings from audits of the service which had identified shortfalls to be actioned. They were receptive to our findings and had already started to implement changes to improve the way they supported people and completed documentation.

There were regular staff meetings and daily meetings to discuss each department and any issues which may arise. This seemed to be working effectively and those involved in these daily meetings felt they were a valuable use of time to ensure there was good oversight. The supervision process was not used effectively to cascade and nurture the shared direction of the service, or to demonstrate inclusiveness to drive improvements and personal development. The provider sought feedback from people and their relatives, to give them an opportunity to contribute and share feedback. Reviews of people’s care plans had not always ensured a fully inclusive and collaborative process of care plan development. The provider’s processes and training provision required a more robust, consistent approach. Risk assessment and care planning processes had not always resulted in care plans which reflected and acknowledged people’s diverse needs. There was a daily walkabout and meetings to monitor the service and help drive improvement. The daily handovers, managers walkabout and 10 at 10 meetings were achieved positive results for people’s care. We saw posters informing people of how to complain and for staff on whistleblowing. This demonstrated an open and transparent culture is being promoted.

The management team told us how they worked to improve the service for people living at Lyndon Croft and their loved ones. They told us about the systems and processes they had in place to ensure people were supported in a compassionate way. The registered manager told us they had felt supported by the new regional manager and the positive impact this has had on the service. The registered manager operated an open door policy, and the regional manager had a presence in the service weekly and was accessible to staff. Many staff told us things had improved since the new registered manager had been in the service. They also told us they felt the registered manager was dedicated to making sure people received the best care.

The systems and processes to monitor the service and drive improvement had recently been improved and this had been noted by people using the service, relatives and staff. However, there was still work required to ensure systems and processes to drive improvement were improved and robust. Feedback gained demonstrated overall that people and relatives had confidence in the manager. However, to ensure all people were included in the running, development and improvements in the service, meetings and care review meetings would benefit from being improved. The provider’s support and oversight of the service had supported the registered manager in the development of the service and its team.

Staff were aware of the staff meetings and told us they had the opportunity to speak up in these or in their supervisions. Staff members told us the registered manager operated an open door policy, and they felt able to raise concerns as they arose. We saw this was the case during the assessment. Formal feedback had been sought from staff, but these forms were undated. The registered manager told us these had been completed recently and there was an analysis of this feedback which was displayed for all to see. Staff told us they knew about the service’s whistleblowing policy and hotline.

The whistleblowing hotline number was displayed around the home and there was a whistleblowing policy and procedure in place. Supervisions and staff meetings had been held where whistleblowing and safeguarding issues and guidance had been discussed. The complaints process was clearly displayed, and any complaints were clearly recorded along with evidence they had been actioned. Residents’ meetings took place and dates for forthcoming meetings were displayed on entering the building. Some relatives felt these could be better communicated via e-mail which would potentially improve on the low attendance. This was an inclusive way to gain feedback and discuss important issues in the service.

Most staff we spoke with felt included in the making of decisions and helping to drive improvement within the service. Most staff felt that their equality and diverse backgrounds and culture were taken into consideration.

Team meetings did take place and staff felt able to speak up and make suggestions during these. Supervisions did take place but had not been used as effectively as they could. The provider told us how they had support systems which they could link into to help staff who needed additional support to develop both language and professional skills. This included the training provided. The provider’s training matrix sent to us at the time of the assessment did not include details of equality and diversity training. Since the assessment has been completed the provider has submitted evidence for this training, however, some staff have still not completed this training.

Staff told us that they understood their roles and responsibilities; however, this knowledge was not always put into practice. For example, safe and correct medicines administration and timely updates to support plans and risk assessments were not always adhered to. The lack of timely actions had the potential to place people using the service at increased risk of harm. Most staff told us the registered manager and senior management were approachable and supportive. The registered manager told us they understood their role and responsibilities. They also told us they felt supported by the provider, and particularly the recently appointed regional manager. Feedback from health professionals and relatives was, overall, positive and they were happy with the service and support provided.

Audits were in place and completed however, there were some shortfalls in these. There was a significant delay when requesting equipment. For example, curtains for multiple areas had been requested to the head office, in July but these still had not delivered as of 15 October 2024. Medication audits needed to include the review of the use of ‘as required’ medicines and to identify where medicines were not being administered as prescribed so that appropriate and timely actions could be taken. Care plan audits did not always identify areas which needed to be more robust or where risk assessments or specific information was missing or contained conflicting information. Care plans reviews needed to be more inclusive. There was a service action plan in place which the registered manager was working through to make improvements. The fire risk assessment which was carried out in November 2023 still had actions outstanding. The registered manager assured us these actions had been completed but had not been signed off as completed. There was no evidence that the progress of this had been checked by the provider. Improvement was required in the oversight of the completion of monitoring charts including fluids and food intake, bowel movements and support with repositioning. We found a lack of evidence that evidence people’s dietary requirements had been met. The staff recruitment process was not robust. Risk assessment for staff with known health conditions had not always been completed to ensure they were suitably supported. We found the induction programme needed to be more robust capturing what happened on each day. The registered manager advised us this had recently been changed to capture this information. We saw there was a file audit in place, but actions were still outstanding. There was an annual DBS declaration completed for all staff. Some families were unaware of the keyworker role and who their loved one’s keyworker was.

People and relatives told us, and we saw that local schools and entertainers came into the home. We saw evidence and were told that people saw health professionals in a timely way. Referrals were made to other health professionals, as appropriate.

Staff and leaders told us how they worked with other health professionals to ensure the best outcomes for people using the service.

A health professional gave positive feedback on the service and the positive outcomes the service achieved for people using the service.

The processes used by the provider required improvement to ensure they involved people using the service. This included gaining consent and involving people in their care planning when first moving into the service and when carrying out care reviews.

The registered manager and provider told us how they took lessons learnt from incidents and shortfalls within the service. This process required further work to ensure this was used robustly to learn lessons and cascade the learning to the staff team. Based on our evidence and observations there has been a proactive approach in making and driving some improvements in recent months. The registered manager and regional manager told us they are aware of where improvements continue to be needed.

Quality assurance and governance systems and processes required improvement to ensure learning was taken from identified shortfalls in the service. This contributed to our identification of areas of required improvements and practices being in place which are not reflective of the regulations. This meant that lessons learnt, and improvements had not consistently been cascaded throughout the service. Improvements in learning from lessons were starting to be made to drive improvement but this was a work in progress. For example, the concerns in relation to staff answering the doorbell, and visitors’ difficulty in exiting the premises and answering telephones continue to be an issue raised by families.