The Lawns

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We reviewed 6 Quality Statements in this key question. We identified 1 breach of regulation.

We found there was a service wide lack of understanding about the Mental Capacity Act and obtaining consents.

People had authorised DoLS in place that had conditions. These conditions were not being met by the provider who told there were no DoLS with conditions, when in fact there were. We also saw unauthorised restraints in use in the form of psychotropic medicines.

Relatives believed people were receiving appropriate care however few had contributed to or even seen their family members care plan.

There was good access to health and social care professionals however, access to community-based appointments was dependent on relatives as staff were not always available to accompany people.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We saw assessments and care plans had been completed. People and their relatives could access these by applying to the registered manager for access to the electronic record system. They could have read only access to view their family members care records.

However, while relatives believed their family members had care that met their needs, few of them had viewed care plans or had a discussion with staff about it. They told us, “There is a care plan, they’ve never gone through it with me in 4 years.” “There is a care plan on the [electronic record system]. Never explained. Updated without reference to me. I don’t worry about it. I know what’s going on.” “Care plans in place? I would think so. It’s fine. I can see it on [electronic record system]. Paperwork is in the office”. “No involvement in care planning. I’m happy with the care. Senior carers let me know what is going on. They ring me to tell me about falls.” “I don’t know about a care plan.” “Care plan? Not that I’m aware of. Care is personalised to (relative’s) needs.” Please note the provider had only been responsible for 1 year and 10 months for the person and their relative not having sufficient information about their care plan.

The registered manager told us they often had informal conversations with people about their care needs and delivery. They found a less formal approach than the annual review enabled people to speak more freely about their needs and wishes. They told us, “We have iPads to take to people to talk with them, also review with family members if there may be changes. It is good to sit and speak to people outside of the care review, it’s less formal and we can come back and add it to the care plan.”

People’s individual needs were not always assessed holistically or fully understood. Risk management systems and practices did not always take a holistic view of people’s needs. For example, we found 1 person was prescribed medication to treat symptoms of contractures, a condition which causes pain and decreased range of motion including impaired joint mobility. This was not mentioned anywhere in their care plan and not cross referenced with pain control management or increased agitation during personal care. Assessments were not always up to date to reflect people’s current needs. We were not assured people were always involved in the assessment of their needs and regular reviews, or that support was provided where needed to maximise their involvement.

Relatives were satisfied their family members were receiving appropriate care dependent on their conditions. They told us, “[My loved one] is supported to lead a healthy life. Food is now soft and moist and is eaten. Their weight is stable. Staff try to provide a varied diet.” A second relative said, “Yes, [my loved one] is supported to live a heathy life. They have small meals, biscuits and Kit Kats and maintain their weight. Maybe too much chocolate.” A third relative told us, “Positive outcomes? Yes. Their mobility is better, and a careful eye is kept on their health needs.”

We spoke with leaders about how fluids were being monitored. They were not clear as to how fluids from jugs placed in people’s rooms were monitored, or how drinks at mealtimes were recorded. They told us they would investigate this and address the lack of accuracy in records.

However, food and fluid records are not a requirement for all people living in care settings, these could just be completed more accurately for people at risk of dehydration, malnutrition or on limited fluids.

Other monitoring such as people’s weights was completed and this fed into areas such as maintaining skin integrity and malnutrition screening. Unfortunately, we saw that peoples air mattress pressure settings did not always match their weight increasing the risk of skin breakdown.

We saw the provider had recently set up a ‘sensory room’. There were few sensory resources however it provided a calm environment that may be beneficial to someone living with dementia.

We were not assured the provider was implementing care that effectively monitored people and provided an accurate picture of their well-being. For example, we were concerned at a lack of fluid being given to people. The totals each day for some people were well below recommended amounts, either because people had not received sufficient fluids or because the monitoring system was not accurately reflecting what had been given. This was of particular concern as some people with low fluid intakes were at increased risk of urinary tract infection according to their care records.

Protocols for ‘as and when’ or PRN medicines had not been put in place, and as a result it was not clear why some medicines were being administered and what effect these had on people. This meant people may be medically restrained without authorisation.

Relatives were satisfied their family members were supported to access healthcare appointments as needed. One relative said, “Yes, they are regularly monitored. There is a regular programme, and health is monitored by the frailty team who visit the home. There is also a link to a local GP.” One relative said their family member had been supported to attend appointments outside of the service saying, “Medical appointments? Staff organise the transport and go with [person].” However, a different relative took responsibility for appointments saying, “I take [my loved one] to hospital appointments. Their mobility has changed in the last few months. They have a wheelchair taxi that I organise”

Staff told us they were concerned people could not attend appointments as planned if they had no relatives who could support them. People who relied on staff for support to appointments may have these postponed as there were not always staff available to take them. This could mean long awaited referrals had to be rebooked and people experiencing symptoms without treatment for longer periods.

We received feedback from health and social care professionals. They told us, “Staff will mention concerns to the district nurses (DNs)... They email photos to the hub to add to records and for advice.” They went on to add, “Staffing is generally OK, there can sometimes not be enough staff. The DN's like staff to accompany them as staff know people and support them, this is often not possible.” Due to people having more complex needs, sometimes due to living with dementia, having staff members present when DN’s attended to them was comforting and aided all to communicate more effectively. It was also essential in some situations to enable safe repositioning of people to access their health complaints.

Other feedback from health and social care professionals included some concerns about the availability of equipment in the service. A professional said, “On several occasions I have discussed appropriate seating with management. They have provided the minimum required seating, a riser recliner armchair and appropriate pressure cushions, and a hospital bed. When a resident had increased demands, I asked that they explore a tilt and space chair. They took a long time but approached the [persons] family to purchase.”

Professionals described a ‘varying degree of competence’ about what should be referred to them. They told us some staff would fill their lists with inappropriate matters that frequently lacked sufficient information, whereas one senior staff member in particular referred appropriate matters, ensured emails were responded to and provided sufficient information.

One healthcare professional reflected, “They do not always engage with us, for example, care home forum meetings or general email requests for information and updates about services provided.” However they also told us, “the Duty Officers at the Lawns are very engaged with these professionals, understanding their roles and working closely with them when needed.”

Senior staff and the management team compiled lists for visiting professionals and ensured people were available for consultations with them as far as was possible. Professionals reflected there could sometimes be inappropriate referrals made so there would be value in spending time to establish guidelines with each professional to ascertain when people should be referred.

We also obtained feedback from health and social care professionals about the services response to requests such as ensuring care staff were present during their visits and repeatedly requesting documentation. When we inspected, senior staff linked with professionals, this meant several different staff could be communicating with professionals, potentially about the same people. Developing a process involving fewer staff may provide a more effective approach.

People and their relatives told us they were supported to live healthy lives. This meant different things to different people. Some liked to know what support was for, others were happy to be supported and not worry about details. One person told us they always had their medicines on time but were not sure what they were all for. A relative echoed these views telling us, “They are on medication but can't remember what it’s all for. District nurses come out to help with dressing their legs.” Another relative told us staff kept their family member informed, “[Family member] is supported to live a healthy life. Staff discuss their health conditions with them, so they understand them.” A third relative told us, “Positive outcomes? Yes. Mobility is better and a careful eye is kept on health needs.”

Staff either did not comment or gave negative feedback about the support they were currently able to offer people. One staff member told us, “Hospital appointments being cancelled last minute for people we support as we don’t have the staff to escort them (not all relatives are able to support their family/ friend to appointments).” Another staff member shared, “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 using a wheelchair rather than walking alongside them to meals for example because it will be quicker.” Staff effectively reinforced there being insufficient staff to provide quality person-centred care to people. Comments included, “I would not put my parents in that home. There are no activities except TV! Care staff are amazing they do the best they can with the number of staff they have. Residents just sit around all day. Half the time you can't find an activity officer and just TV on.”

People were not always supported to live more healthy lives by effective processes. There were times when staff could not be allocated to attend appointments, even when long standing and should a person not have a friend or relative able to take them to appointments, there were no guarantees they would be able to attend.

We were also informed by a healthcare professional that instructions given about people’s care were not always immediately acted upon taking several days to update care plans.

People were referred to appropriate services should they require additional input with regards to their mental or physical health.

We received mixed feedback from relatives. Comments include, “There is a care plan on [electronic record] system. It was never explained, and it gets updated without reference to me”, “I don’t get updates about [my loved one’s] health: I never get any information. They have family meetings when I am working so cannot go” and “Took a lot of insistence and checking up and access to [electronic record system] and now [my loved one] has bath and hair wash weekly. I was not told about [electronic recording], I found out when asking for access to [their] care notes. The then manager did not know the procedure. I have not been offered a review of care plan.” Some relatives believed their family members were regularly monitored in terms of their health and well-being. One relative told us, “They keep me fully informed by email, and if [my loved one] needs chiropody, dentist or optician they deal with it and keep me fully informed. Communication with the home is good, I have nothing negative to say.”

We received mixed feedback from staff about monitoring and improving outcomes for people they support. Comments include, “I do not feel that we always give choice, for example [staff will decide] person will have a tea without asking the person. Although [some people] are most likely to not respond, a visual could be used. I do not think it’s fair to assume. Majority of the time this tends to happen to save time which is sad but its due to short staffing”, “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. 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 “All residents are given choices in how their care is carried out. I ask regularly if they are happy with how the staff attend to their needs and remain available for the residents to discuss any concerns they have.”

People were not always involved or consulted about the reviews of concerns, accidents, incidents, and adverse events and in planning to prevent similar incidents in the future.

We were not assured care plans were always updated to provide clear and concise guidance for staff as to how to support people in times of distress. A person’s records which instructed staff to complete behaviour monitoring charts for administration of an antipsychotic medication they were prescribed. We found monitoring charts were not completed for any incidents prior to administration of antipsychotic medication, and a risk assessment had not been completed to identify triggers and actions staff can take to mitigate periods of agitation. This meant that it was not possible to understand why chemical restraint was being used and if it was the least restrictive option available to staff at the time.

This increased the risk of unlawful use of chemical restraint, overdose and over medicating people with psychotropic medicines. People's needs were not always effectively monitored, or lessons learned from incidents and accidents reflected within their care plans.

Risks associated with malnutrition and dehydration were not reflected in people’s records. Information in people's care plans was not always clear, and some was contradictory. One person’s records which stated they are compliant with taking all their medication and other records stated they were not always compliant and cooperative with taking their medicines. This placed people at risk of not having their needs met.

The provider used an electronic record system, the data from which could be downloaded and analysed.

Relatives understood they should be included in discussions about people’s care if they held Lasting Powers of Attorney (LPA).

Staff training in the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguarding (DoLS) was at 93% completion when we inspected. However, staff either had not completed the training or had no recollection of it except it had been online and not face-to-face.

Staff told us knowledge of MCA was not relevant to their post, that the duty officers completed MCA ‘work’, and they had completed training, however it did not tell them how to practically work in line with the Act. Comments included, “I have received MCA training but again this was more about MCA and not to complete the assessments” and “I do not recall any MCA specific training recently, and especially not face to face, however I believe there was training in regard to this online.”

We found consents had not been completed and signed, consents that were signed by staff who had no legal powers to do so. Best interest decisions completed by staff were not supported by a MCA assessment to evidence whether the person had capacity to make decisions, and in some cases had been made when the person had an LPA in place. The person named their LPA as a person they trusted to represent their views when decisions were made, this had not always been considered by staff.

DoLS may be authorised with conditions, these can be varied and may, for example, ensure a person can continue to attend certain community settings such as a church to maintain their faith. A person had conditions for the provider to complete MCA assessments and subsequent best interest decisions for consents for their care plan, medicines and information sharing and to ensure these were regularly reviewed. There were no MCA assessments or best interest decisions on their care record and a relative had signed consents stating they had an LPA. We found no LPA in the care record to support this statement. We also found 8 DoLS authorisations had not been notified to CQC.

A person who was prescribed a sedating medication had no legal consent in place for the medicine, this had been signed by staff members in their best interest. In addition, there had been no DoLS application for use of this medicine which was a form of restraint.

There were numerous inconsistencies around MCA and consent, and it was evident there was a lack of understanding of MCA at all levels of staffing at the Lawns, including senior management who had not noted concerns about consent or MCA at any recent audits. A separate pillar audit completed by the provider had identified some problems with MCA and consent however, it had not triggered further investigation or actions at the time of our inspection. We have issued a Warning Notice covering breaches of regulation in this area.