The Lawns

On this page

• Overview
• Kindness, compassion and dignity
• Treating people as individuals
• Independence, choice and control
• Responding to people’s immediate needs
• Workforce wellbeing and enablement

We reviewed 5 Quality Statements in this key question. We found 1 breach of the legal regulations in relation to dignity and respect.

We were not assured people’s privacy and dignity was always fully respected, and at times staff had to be more focused on tasks than people and their wellbeing. Support was inconsistent and not always respectful.

The service did not always ensure staff had the skills and time to recognise when and how to give people compassionate support when they need it. Training to understand the importance of dignity and respect was not provided to staff. Staff told us there was high turnover in the management team and this affected their wellbeing, leading to low staff morale. Staff did not always feel supported by managers and the organisation. People were cared for by kind and polite staff. Staff spoke about people in a positive way. They knew them well and were able to tell us about people's preferences and how to care for them.

This service scored 55 (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 gave only positive feedback about the care team. They liked the fact many care staff had been long term team members at the Lawns and were warm and friendly. They told us, “The carers are knowledgeable and friendly. I never worry about the carers, when I observe them, I see they are proactive. The cook knows what [relative] likes. They are well looked after. Staff talk to them as a person, not as a patient. [Relative] is blunt, and they react well when they get a bit rude.” Another said, “Individual staff are lovely, the permanent are ones really lovely, and they look out for [relative] and encourage me to follow things up like access to the care notes.” A third relative told us, “I think staff are generally attentive and are warm and welcoming. Staff consider their social and emotional needs but not formally. They are non-verbal after a stroke, some staff encourage them to talk, not a care home decision but rather some individual carers.”

Staff told us they were committed to providing a person-centred service and tried to ensure people received care as they wanted it delivered. However, again in their opinion, due to a lack of staffing, they had not always been able to do this. A staff member told us, “Staff have very little time for people's individual needs and to promote independence; with tasks being completed as quickly as possible to move on to the next [person].” A second staff member, after sharing details of their current experiences of working at the Lawns told us, “As you can imagine the residents were meeting the needs of the service and the home was institutional. Person centred care was lost.”

There was also a consensus that staff were being asked to complete tasks they believed were not possible. For example, a staff member shared, “There were several times when I did disagree with the messages coming down from the managers regarding medication, and the time at which people should be got up to ensure at least 10 people were up, dressed and had breakfast before the day staff arrived at 7am… It is very hard to uphold a high standard of care without adequate staffing levels. That being said, everyone [staff members] tried their best and truly cared about the clients.” A second staff member shared similar views saying, “Staffing? It isn't because staff are not trying, they have been told the medicines round is too long and should only be 60 minutes. It isn't easy, if someone is still asleep you go back for them, if someone is on end of life it could take 30 minutes to give their medicines. Also, they want people to have 20 minutes allocated to get them up. This is what we should not be, we must not get task orientated or task led. All up and ready for activities by 10am is not person-centred care.”

We received no negative feedback about kindness, caring and dignity from partners. A health and social care professional told us they had attended the service numerous times speaking to different people and relatives. They told us, “not a single one of the residents had any complaints regarding the staff and how they are treated. I observed a particular duty officer have a fantastic rapport with the residents, they were passionate about them and their care. They were very aware of their needs, and it was very obvious to me how much they cared for the residents at the Lawns.”

We saw several areas of concern when on site at the Lawns with regard to dignity and privacy and have issued a warning notice for breaches of regulation in this area.

Soon after arriving at the service, we were looking around the premises and saw a person had been undressed from the waist down and left on the commode with their door open, they were in full view of the corridor and calling to staff for support. Staff did not respond immediately leaving them calling for some while. A second person had been unwell and returned to bed, again, their door was wide open and they and their soiled commode in full view of anyone passing their room.

A newly admitted person had stacked packets of incontinence pads in their room, these informed anyone seeing them of a personal health condition they may have wished to remain private. Other longer-term residents also had stacked pads in their room. There were pad storage cupboards however there were problems as staff would grab pads, not necessarily from people own pad stock from the communal stores.

Other concerns witnessed included inappropriate and patronising support that was not in line with a person’s care plan provided to them during lunch, a person told us they often had to wait some time to be supported to another area in the service as people who needed personal care were dealt with first, and several toiletry items were discarded in bathrooms indicating they could be shared between different people, or at the very least people’s possessions had not been treated respectfully.

People and their relatives felt they were treated well, and that staff knew them well. A relative told us how well their family member was known to staff. They said, “Yes, staff are considerate of their emotional needs. They are happy when we visit and have settled well.” They added that, “Communication is in a way which is understood.”

Another relative told us, “Staff have a kind and caring approach. An example being general attentiveness, they bring tea with sugar at 11am.”

A person at the Lawns enjoyed being up early and able to get into the garden. They told us, "I prefer waking up early, someone is always around if I need help in the early mornings."

Feedback from staff was not hugely positive when asked if people were treated as individuals and if care was person centred. They reflected a team who were caring of people but at times failed to care as well as they wanted to. A staff member told us, “I would not put my parents in that home. There are no activities except TV! The care staff are amazing, they do the best they can with the amount of staff they have.” Another staff member told us, “I thought [3 x staff names] all had amazingly in-depth knowledge about every single resident and truly cared about their wellbeing and happiness.” A third staff member said, “We have been unable to provide them with the 1-to-1 support they require, such as general chats and just ensuring they are ok.” And finally a staff member who wasn’t in the care team said, “I do not think there are enough staff to meet needs, what needs are met are basic and there is little time to spend taking residents out or catering for a hobby, even a chat sometimes is hurried.”

We saw lots of positive examples of caring where it was clear staff knew people well and could easily manage to comfort them and chat with them. However, we also saw an agency staff member not following a person’s care plan and supporting them with their meal inappropriately. Following this support, the person was left alone for a period during which they were given a dessert. The dessert was left with them a large piece of sponge cake which they attempted to eat. This was unsuccessful as all their foods should be cut into small, bite sized pieces. They dropped the food on themselves without the staff support their care plan stipulated. The staff member was elsewhere supporting another person.

As previously mentioned, we also saw a person had been supported onto their commode in a state of undress and left with their door wide open. They were also calling for help. The fact staff did not immediately respond to the person and had left them exposed to being seen by anyone from the corridor did not indicate them being treated as an individual.

People had care plans containing information such as ‘prone to UTI’s’, and ‘becomes agitated during personal care’. The information was accompanied with guidance such as to swap care assistants supporting the person, and to encourage fluids. Care notes did not reflect these specific care plans were always followed. People had poor fluid intake despite being at risk of UTI’s. A person was prescribed PRN Lorazepam, we found no record to indicate what it was prescribed for and when to administer it.

Most relatives told us their family member had no end-of-life plan in place.

People felt they had some choice and control over their care. One person said they were supported in their most favourable routine, going to bed quite early and getting up early, and who felt they had staff around to support them with their independence. They also believed if they wanted to go to the shop they could, telling us, "I could ask to go to the shop, and someone would help me, but I have everything I need here" They did wish they could be supported to go to the beach in good weather though!

A second person told us they felt supported and cared for, getting up when they wanted, and preferring an earlier morning. They did however feel their mobility was somewhat restricted as they used a wheelchair. They told us, "It’s good, I can't complain."

Relatives reflected differing views as to whether people had control over their care. A relative told us, “[Person] has no control over care as they are not living in reality. We are not involved in care planning but I’m happy with the care. Senior carers let me know what is going on. They ring me to tell me about falls.” A second relative told us, “Control over care? My relative is a creature of habit. They get up at the same time every day and know when they’re going to have a shower.”

All relatives told us they believed there was no discrimination or barriers to their family members receiving care. They also told us there had been no discussions about future care and end of life provision.

Staff told us, “I do not feel that we always promote independence. For example, 'she will have a tea' without asking the person [what they want to drink].” So, they believed people were not always having even the simplest of choices about their care.

Another member said, “I don’t feel the service empowers people’s independence as again, when short of staff, you will very often see staff will support people with a wheelchair rather than walking alongside them down for meals because it will be quicker.” This meant people who were less mobile could lose their ability to walk sooner as they were not properly supported to maintain it, while people able to mobilise independently or those already using wheelchairs would be appropriately supported. They continued, “I do feel people’s needs and wishes are considered as you do often hear staff giving them choice in things such as where to sit what they would like to drink what they would like to watch on the TV etc” and “Staff have very little time for people's individual needs/ to promote independence with tasks being completed as quickly as possible to move on to the next."

The Short Observational Framework for Inspection (SOFI) is a Framework for directly observing and reporting on the quality of care experienced by people who may not be able to describe this themselves. We completed SOFI observations of people in the lounge / dining area from 09:15 recording every 5 minutes about 5 people in the room.

For 1 person it took 40 minutes for staff to engage with them. They had brief contacts when a drink was offered and when they stood up, they had a pressure alert when they moved. At one point they also began to ‘play’ with the cable on a footstool. This was taken away by staff. After 40 minutes of attempting to communicate with peers, speaking to our inspector and looking for stimulation in their environment, staff gave them a book and sat for a few minutes with them. The person had been seeking either stimulation or contact with others for 40 minutes when staff could have provided sensory stimulus equipment for them when they were first seated in the room. Small actions can make an enormous difference to peoples’ experiences.

We reviewed care records that were of varying quality, in part due to the confused approach to capacity, consent and MCA. Each care plan identified needs such as health conditions accompanying each with a clear definition. Care notes were regularly added, most of which were brief and set responses to care prompts. We could not review all care plans and notes however found a concern in language used in one record. It read, “Request made to DN to review [person’s] hand as its smelly and at risk of infection.” Whilst this may be factual, the terminology was quite offensive and more professional terms should be used.

People were not involved in planning their care delivery or in reviews. The registered manager told us they obtained informal comments and information to inform care plans however people were unaware if they had contributed to the plans.

While staff found certain times of the day very busy and difficult to manage, people, because of staff’s hard work had not felt too much impact. We heard most call bells being answered within reasonable times, but people told us they sometimes had to wait longer than they wanted to get support from staff. A relative told us, “Can call for help and no one hears. If buzzer or if mat, might be five minutes or could be 20 minutes.” A second relative told us, “Once a woman spilt a drink and pressed the bell, after 5 or 10 minutes I went to find someone.” A third relative said, “Call bell responses are variable. 5-10 minutes waits are acceptable. Other times they ring and ring.”

A staff member gave an example of how staffing might work during a shift at the Lawns. They told us, “Two [staff] supporting 1 person to transfer, 1 [staff] to answer bells, leaving 1 [staff] to be expected to help all other people with comfort rounds, making drinks and managing general welfare.” This staff member believed they needed additional staff deployed to meet people’s needs. If for example, 2 staff were engaged with a person during personal care or toileting it could leave insufficient staffing to support people with other needs such as transfers, comfort breaks, drinks and snacks. In addition, staff also need to take breaks, complete records and training.

A senior staff member reflected that staff had expressed sadness at not being able to take time to look after people, complete paperwork and offer people baths.

We observed most staff interacting with people in a person-centred way, knowing them as individuals, taking their wishes into account and respecting their choices, to achieve the best possible outcomes for them. We observed 1 person sitting in the armchair in the lounge, becoming increasingly restless and looking for something to do. Person was repeatedly getting up from their chair, which set off loud chair alarm. Staff were busy supporting other people and did not provide any meaningful activity to them for 40 minutes, until activity staff arrived.

We observed call bell activated in another person’s bedroom being active for over 10 minutes before it was answered by staff member.

We observed 1 person becoming increasingly unsettled whilst being supported with their food by a staff member putting food into their mouth. We reviewed their care plan, which stated this person was able to eat independently but needed close supervision from staff during mealtimes. We observed person left unsupervised eating their lunch as staff left to answer call bells in other peoples’ bedrooms.

Staff and the management team told us there were 1-to-1 supervision meetings however, appraisals had been stopped. The registered manager told us, since they commenced in post in October 2023, they had 1, 1-to-1 supervision meeting which was arranged without their knowledge for the day they returned from annual leave. They also told us that weekly catch-up chats with their line manager were not recorded and had been of limited support to them. A member of staff told us: “I have not had supervision since December 2023, although I believe the tracker says I have, this is not true.”

A staff member told us the matrix retained of all supervisions did not show how few supervisions they had, instead, more regular meetings were recorded. Another staff member had participated in 2 supervision meetings since May 2024 which as a new staff member they felt wasn’t sufficient and a third staff member said supervision meetings were ‘hit and miss’.

The provider held 1-to-1 supervision meetings with all staff and recorded this information on a matrix. Meetings should be held at regular intervals however staff reported they did not have meetings as frequently as they should have them. Reduction of non-contact time for senior staff also impacted on meetings as there were fewer opportunities in which to book time with staff, particularly care staff who were needed to be completing care tasks.

The registered manager also said they had only attended 2 management meetings since they had commenced in post, both attended by the CEO of the provider leaving little opportunity for supportive conversations with peers and line managers.