What the CQC found at Lynfield

Inspectors saw care that was kind and focused on each person's needs. Care aimed to protect dignity, privacy and human rights.

“Care interactions we observed were kind and focussed on each person's needs.” from the report

Inspectors found that medicines for distress and anxiety were used appropriately and closely monitored. Other medicines were also given safely.

“Medicines were well managed and medicines to help people with their distress and anxiety were closely monitored and given appropriately.” from the report

Staff knew how to recognise and report abuse. The provider worked with the local authority when safeguarding concerns were investigated.

“Staff were clear about how to recognise and report signs of abuse and had received training about this.” from the report

The home worked with a range of health and social care professionals to support people with complex needs.

“The service worked well in partnership with many other health and social care professionals.” from the report

Some staff files did not contain full employment histories or enough interview evidence to show that applicants had the right skills and qualities. This was a breach of Regulation 19.

“Recruitment procedures were not sufficiently robust. This was a breach of regulation 19 (Fit and proper persons employed) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report

Inspectors found problems including an easily overridden window restrictor, an unsecured wardrobe, an unrepaired showerhead and uncovered hot water pipes. The risks linked to a choking aid had not been fully assessed, and the device was removed after the inspection.

“However, some environmental risks had not been fully considered and mitigated.” from the report

Accident and incident records did not always contain enough detail or lead to proper checks that care plans had been followed. Inspectors recommended a more robust review of these records.

“Accident and incident records, although signed off by senior staff, did not always lead to robust analysis to see if lessons could be learned to make improvements and reduce future risk.” from the report

Inspectors found that people were sometimes treated or spoken to as if they were young children rather than adults. They said this could be demeaning and affect dignity.

“However, judged that the culture of the service was to occasionally treat the people who used the service as if they were young children rather than adults.” from the report

Quality checks and audits did not identify all the problems found by inspectors. Senior provider oversight also needed to be stronger.

“These checks were not fully effective and some improved oversight was needed in some areas.” from the report