The Lawns

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

We reviewed 8 Quality Statements in this key question. We found 3 breaches of the legal regulations in relation to safe care and treatment, premises and equipment, and staff skills and experience.

The provider identified risks to people’s health, safety and welfare for example, risks associated with epilepsy, contractures, constipation, dehydration and malnutrition. However, they were not always mitigated effectively in a person-centred way, or following best practice guidance. We were not assured appropriate support was in place to enable staff to prevent avoidable harm.

Care plans were not always clear, concise and did not provide clear guidance to staff. For example, when people had been prescribed antipsychotic medication to support them with anxiety and agitation, their care plan did not provide clear guidance to staff on how to recognise signs and symptoms they may display before their anxiety escalates, how to support them with their behaviour when they become anxious and did not mention use of antipsychotics as a last resort.

Medicines were not always managed safely. Risks associated with use of high-risk medications like anticoagulants or potentially flammable creams and emollients were not assessed for each individual.

We were not assured the provider deployed sufficient number of staff to meet people’s needs. Staff had not received all the training identified as necessary to conduct regulated activities, or to maintain necessary skills to meet the needs of people they cared for. For example, staff did not receive any epilepsy, end of life, dignity and respect, or skin integrity and pressure ulcers training. However, staff and leaders mostly understood their responsibilities for safeguarding people. Care staff consistently told us the actions they would take should they suspect abuse had occurred.

There were effective and fully embedded processes for assessing the risk of, preventing, detecting and controlling the spread of infections.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We received no direct feedback from people or their relatives in this area.

We received feedback from health and social care professionals about The Lawns. One healthcare professional told us they found information shared with the service was not always shared and noted. They told us, “In particular, I have been asked multiple time to provide hand signed DNARs (Do Not Attempt Resuscitation) and re-write those that have been provided as a copy or have previous addresses on them. I have sent them the Pan Dorset document and informed them about the validity of the coloured copy DNAR. This is something than I often waste my breath repeating and being asked by the deputy manager to discuss with the company. I have not agreed to speak further about this as they have the relevant documents.”

We received mixed feedback about learning from accidents and incidents being shared with the staff team however, 1 staff member told us they felt the registered managers assessment and summaries of learning shared on the electronic record system were well written and relevant.

Another staff member told us, “[quality and compliance system] is used for accidents and incidents as well as [electronic record system]. Staff tend to record on the electronic record and may not add the same incident to the quality and compliance system, they forget or have no time. There is a pilot happening to link the 2 systems but it’s early days and we not part of the pilot. This means that if you run a report on electronic record system and one on the quality and compliance system, the outcomes will be different.

Accidents and incidents were recorded and added to a quality and compliance system where they could be reviewed by the registered manager and senior managers. This ensured any identified actions were known throughout the provider. Staff were informed of any learning from accidents and incidents during handover meetings where they could discuss actions. Staff meetings also updated staff on learning.

As mentioned by staff earlier in this section, there was frequently a disparity between reports run on 2 systems used to monitor incidents. The Registered Manager mitigated the risk by manually updating the systems. However this took considerable time, taking them away from other duties.

We received mixed feedback from people and their relatives about maintaining continuity of care and their involvement in creating and reviewing people’s care records.

Relatives commented: “In hospital [my loved one] had heavy pain medication so had strong laxatives; now off pain killers but [they] were still given the strong laxatives. I had to raise it with staff after [my relative] was there 2 or 3 weeks. [They] are diabetic and has had up to date monitoring, now back to old style monitoring”, “There is a care plan. They never gone through it with me in 4 years” and “[My loved one] has a care plan, recently appraised, and it looked at how [they] were, how [they] are now and aims to achieve.” It is important to note, the current provider, at the time of our inspection had only been responsible for 1 year and 10 months during which their care plan had not been discussed with the person.

We received mixed feedback from staff about safety and continuity of care and about their involvement in care planning. Staff told us, “I feel I have enough experience to deal with the majority of our residents needs however, there are some residents needs which I feel would be better catered for in a different setting such as a nursing home or a more secure environment for those with advanced dementia” and

“I feel we are given enough information within the care plans to keep the people we support safe. However, very often we have shifts with unsafe staffing levels. This has been difficult as we try to ensure all the people we support needs are met, but at times have been unsuccessful in doing so.” We have referred to staffing levels elsewhere in this assessment report, for example, people not being offered baths or showers instead having washes or being offered support with showering at odd times such as mid afternoon rather than when they got up or before bed.

We received mixed feedback from health and social care professionals about maintaining partnership working to ensure safe systems of care, in which safety is managed, monitored and assured. Comments included, “There is often a varying degree of competence between the seniors who I predominantly deal with during my visits. One in particular often fills my appointment ledger with inappropriate concerns, often with a lack of information to understand their concern.

Another senior, [name], stands out as an asset to the care home; [they] are often dealing with office duties, liaising with external agencies, managing medication rounds and leading the other carers. Despite this they manage to complete all tasks asked of [them]” and “I did not have many dealings / involvement with the management team. I feel that an area for improvement would definitely be for management to be more approachable and available to visitors / families. However, the duty officers were nothing but helpful, polite, engaging and passionate. However, I did find at times the suggestions or concerns I raised were not dealt with quick enough. I do feel that this could be down to the staffing level at the Lawns and that the duty officers are so busy that things are being missed. I asked for physio input / referral, and it was weeks, and another reminder, before any action was taken. I also asked for feedback on my suggestion of a SaLT (Speech and Language Therapy) assessment being required. I had no response after 2 urgent emails and so ended up calling and asking the duty officer to find the notes for me.”

We were not assured provider established effective processes of safety and continuity of care through a collaborative, joined-up approach to safety that involved people in their care along with staff and other partners.

We were not assured care and support was always planned and organised with people, together with partners and communities in ways that ensured continuity. Processes to gather the views of people who use services, partners and staff were not always effective and their views not always considered. People and their relatives told us they were not always involved in planning and organising their care.

We did however see staff support a person positively when, following a fall, they needed paramedics and possibly a trip to hospital. The senior care staff member asembeled their 'grab bag' with hospital details and medicines promptly which was given to paramedics for their reference. This process worked well for the person however despite containing medicines and confidential information the bag was not put away when paramedics left the premises which could have posed a risk to service users.

Most people and their relatives believed the service was safe. A relative told us, “She feels safe and feels that if she had a problem she could speak to staff or one of her sons who lives in the area and visits fairly often.” A second relative said, “He feels safe and would talk to staff if he needed too.” A person living at the Lawns told us, “I feel very safe and very supported."

We received mixed feedback from health and social care professionals. One health professional commented: “There have been several instances of medication errors. Often when we have made changes, always communicated in an email summary, and these changes have not been made. The home has always been good at informing our team and self-referring to safeguarding.”

Another professional told us: “It does not always feel that our more general issues are responded to. For example, district nurses have been asking to have a carer accompany them on their visits. This I believe is vital for resident safety, many residents are cognitively impaired, and it is possible the wrong resident may be approached in error and may need 2 individuals to support with repositioning / accessing the relevant part of the body etc. and it is reassuring to the patient if someone they know well is with them for a nursing procedure. There has been a very slow response to this from management despite requests.”

Staff and leaders mostly understood their responsibilities for safeguarding people. Care staff consistently told us the actions they would take should they suspect abuse had occurred. They told us, “If I thought someone was being abused, I would whistle-blow, make my manager aware and I could also use the 'speak up' service.” And “If I had concerns of someone being abused, I would report this to my manager. I would also inform safeguarding of my concern.”

We were concerned as a member of staff who was not part of the care team told us, “If I saw they had bruises on them I wouldn't mention it to anyone. I assume that is picked up by someone else, a care staff member. I would tell staff if I saw something dangerous though.” Safeguarding is the responsibility of all staff, and we expect a housekeeper, cook or hairdresser to mention if they noted a bruise or someone acting in a concerning manner as they may be the first or only person to note this.

A head of service audit completed in July highlighted lessons learned from safeguarding were not thorough and training in the benefits of ‘lessons learned’ was needed to benefit the service.

Staff had not always demonstrated good understanding around safeguarding procedures. For example, potentially harmful chemicals and medicines were not always locked away despite signs on the door stating ‘Keep locked at all times’ and were accessible in bedrooms and communal bathrooms. We raised this immediately with the manager.

Fire evacuation doors were not always securely latched. We were able to open a fire exit door in the corridor on the ground floor by gently pushing it without using the door handle. Staff attended quickly when an alarm sounded to alert them of the open door, however a service user could have left unattended through the door.

The home had a safeguarding policy in place. We reviewed the safeguarding records and found the file also held useful flow charts for falls and medicines errors to indicate what should be alerted and what should not.

We reviewed all recent safeguarding incidents, and all had appropriate actions and outcomes. There were also clear chronologies recorded to give an overview of what actions had been taken, when and by whom.

There were high completion rates of staff training for safeguarding of adults and children courses however the completion of safeguarding for managers was 0%.

Feedback about risk management was varied. One relative felt risks had been managed telling us, “Yes, feels risks are managed and they feel safe.” Another relative had mixed experiences of risks being managed for their family member. They told us, “They moved them downstairs as staff were concerned they could fall or forget where their room was. Staff also adjusted their care, now they have a walking frame and sometimes use a wheelchair.” They went on to tell us, “There has been no risk assessment. They never reviewed the care plan, but the care is reviewed every year as they have a Deprivation of Liberty Safeguarding (DoLS) authorised.”

Staff told us they did not always have enough information about people’s support needs and how to mitigate the risks people faced every day to keep them safe. Comments included: “Sometimes we are not made aware of changes in dietary / soft food requirements until late or after we have served meals.”

Staff were not always able to be involved in the creation and updating of people’s care plans. Staff told us: “Seniors used to have allocated paperwork days to discuss with residents their care, build relationships with families and talk to people in more depth about the care and support they are given, and analyse day-to-day personal care. This was literally gone over night. The impact not only has led to care plans being out of date, risks are not being identified and staff are becoming upset.”

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

During our SOFI, we observed people were able to move around the house and grounds freely. We observed a member of staff had served a piece of cake to a person living with dementia. They were left unsupervised and attempted to eat the cake independently in 1 piece but dropped it on their lap. We checked the person’s care plan which stated they were at risk of placing items into their mouth whilst eating, therefore needed supervision while they ate to prevent this and to reduce risk of choking. Their meals needed to be cut into small bite sized pieces and encouraged to drink fluids between mouthfuls of food.

We observed another person walking independently unaided in the corridor on the first floor and calling for help. Staff, alerted by inspectors, assisted the person to their bedroom and prompted them to use their walking frame. We found a pressure mat in the person’s bedroom which activated the call bell. We also saw there was no window restrictor in their bedroom and the window had been opened wide. The person was living with dementia.

This meant risks to people’s health and safety were not effectively mitigated which put them at increased risk of avoidable harm.

People’s risks were assessed before they started to use the service and added to as needed. Risk assessments were created and maintained within the provider electronic care planning system. However, care plans and risk assessments were not always updated regularly or as things changed.

We were not assured risks were fully assessed and mitigated. We were not assured the provider had always identified and mitigated risks to people’s health, safety and welfare effectively or followed best practice guidance.

Relevant health and safety concerns were not always included in people’s care plans. For example, risks associated with epileptic seizures, with contractures or the risk of constipation.

We were not assured appropriate support and guidance was in place to support and enable staff to prevent avoidable harm. Care plans were not always clear and consistent, some contained conflicting and contradictory information and did not provide sufficient guidance for staff to keep people safe.

Senior staff were responsible for completing tasks such as risk assessments about people. Due to a reduction in their non-contact time, they had just 7 hours per week to complete risk assessments, care plans, reviews, audits, and complete tasks such as conducting 1-to-1 supervisions with staff. There was limited capacity to ensure risks were managed.

A relative identified problems with the safety of their family members environment. They told us, “It is safe, but I do have a couple of reservations. Last year they were quite mobile. It’s a big home and they are upstairs… it’s a bit isolated and I would like them to be on the ground floor. They like to go to their room. They have got a floor mat if they go towards the toilet, but staff can’t be with them immediately. So far, they had 2 falls trying to get to the toilet and had been found on the floor. They can call for help, but no one hears. If the buzzer or mat sounds, it might be 5 minutes or could be 20 minutes. I mentioned it a month ago and they said no other rooms were available, but I am going to follow it up. There are not enough staff. There is a problem recruiting, they use agency staff. When questioned they said they were within government ratios. Its spacious [at the Lawns] but one end of the building to the other is a distance.”

Staff and leaders did not tell us much about the environment, however 2 members of staff spoke unfavourably about the environment in relation to cleanliness and appearance. On the whole, most staff were more concerned about other issues such as staffing levels than the premises

We found some aspects of the premises were not safe and have included them in a warning notice issued for breaches of regulation.

In the room of a person who lived with dementia, there was no window restrictor. These should restrict openings to 100mm to minimise the risk of falling from height. We checked fire exits and 1 had not been closed properly meaning when we pushed it, the door opened.

We also found 2 tall, glass cabinets had no wall anchors. There are no specific guidelines about this however, providers have a responsibility to risk assess hazards and the cabinets could tip should someone fall against them or use them for support.

A door closer on a fire door had become disconnected and was not operational. The provider contacted their properties management to arrange for a contractor to assess these jobs during our assessment visits.

We saw bathrooms left with doors unlocked and open that had signs on them to remind staff to close and lock them after each use as creams were stored in them. One bathroom also had the cabinet that contained prescription topical medicines left open as well as the bathroom door left open. This left prescription lotions and creams accessible to anyone in the service.

We saw a cupboard that was labelled as ‘fire door keep locked shut’, with an additional printed sign that read, ‘keep locked at all times’, was unlocked. This cupboard held containers of laundry detergent, stain remover and fabric conditioner. These items should be locked away.

In the communal lounge on the ground floor the curtains were hanging off the curtain track and between them a fire exit sign hung on chains. This was to ensure it was visible when the curtains were closed. The sign had warped and curled up, making it less visible and readable, and needed to be mounted on a hard backing such as wood or acrylic to prevent this happening again.

There were clear and effective processes to ensure scheduled maintenance and unscheduled repairs were booked. An online system enabled staff to photograph the item that needed attention, which was shared directly with the property maintenance department who arranged for contractors to attend and quote.

This was an effective system however it relied on staff being aware of requirements, and risks concerning premises safety being reported. We were not assured this was the case as we saw maintenance tasks that had not been identified or reported to the properties department.

People and their relatives gave mixed feedback about whether there were sufficient staff deployed to meet people’s needs. A relative told us, “Staff are good, she feels supported and doesn't have to wait long if she needs help.”

However, other relatives told us, “There are not enough staff. You can often wait for the front door to be opened. Could be 3 or 4 [visitors] waiting.”

Another relative said, “I saw a lady fall over and there were no staff around. I see a lot of bank [agency] staff and see them saying they are not sure what to do. I know you can’t have 1-to-1 [staffing], but I think when I sit there and there is no member of staff with 10 residents in the room, when I have seen a woman fall, there are not enough staff. No continuity. They need continuity. Some staff are trained and are on the ball, others I have not seen before and don’t see again.” Another relative told us, “Personal hygiene is an issue. They get a body wash daily and a bath once a week, but I was not sure and followed it up and got access to their care notes. They did not have their hair washed because they were not going to the hairdresser and no bath for 3 weeks. Took a lot of insistence and checking up, and access to the [electronic record] system, and now they have a bath and hair wash weekly.”

A person using the service felt more staff were needed but those who worked there were particularly good. They were concerned as it can take them a long time to get back to their room after meals as they relied on staff support to move about the premises. We asked how long they had to wait, and they responded, "not too long, but it takes as long as it takes.” Others commented on the time it could take to respond to call bells and staff looking tired and under pressure.

All feedback from people and their relatives reflected they believed staff in permanent roles at the Lawns were kind and caring and good at their job.

Staff and leaders told us there were not enough staff deployed to meet peoples care needs. For example, while people’s personal hygiene was maintained, it had been noted that people were not regularly being offered baths or showers.

When people were offered baths, they often refused them as they were offered during quiet times such as the afternoon, not when they got up or before bed when they usually happened.

A staff member told us, “Not enough staff. Care Dorset [Limited] are penny pinching and won't employ more staff or get agency staff in… They are even getting senior staff to do care roles which then impacts on their own roles.”

Another staff member said, “There have very often been shifts where we have been at, what I feel was an unsafe staffing level. Care Dorset [Limited] changed the dependency tracker, which then reduced the amount of care staff required… This has been difficult as we try to ensure all the people we support’s needs are met, but at times have been unsuccessful in doing so. We have been unable to provide them with the 1-to-1 support they require such as having general chats and just ensuring they are ok. What has been a very upsetting experience is, when we have people approaching end of life, and no one is able to sit with them offering them the reassurance they deserve. And hospital appointments being cancelled last minute for people we support as we don’t have the staff to escort them to appointments.”

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We saw staff supporting people at mealtimes and found there to be a mix of appropriate and less appropriate support. We will address this later in this report. Staff demonstrated they understood their roles and associated responsibilities. We observed most people appeared relaxed and at ease when being supported by staff.

We also monitored how long it took staff to respond to the nurse call system. We heard most calls being cancelled after a few minutes however 1 lasted over 10 minutes before staff attended to the person. We found they had called for staff to get them a drink, however it may have been a call for personal care, or to inform of a fall that was not answered promptly.

A healthcare professional told us, “Lack of staff is clear. They have employed new staff, though often rely on agency workers. They always seem to be working hard but lack numbers. During meal / medication rounds they often struggle to meet to ad hoc demands of visitors / residents needing toilet etc.”

Staff were safely recruited to work for Care Dorset Limited. We reviewed 6 staff recruitment records and all bar 1 had all the required Schedule 3 checks and information in. There was a CV missing from the 6th record which we raised with the registered manager, who found the document and replaced it in the record. This had not been noted in recent audits of staff records.

Staff completed an induction on commencing in post. Mandatory training was completed and updated at appropriate intervals. Most training was online, and staff told us, “The training provided by Care Dorset lacks depth and is very basic and not aimed at a senior level. I feel they could do better. For example, sourcing training that challenges and makes staff curious. I feel the training ticks the box for compliance and that’s good enough.”

Other staff could not recall having training in the Mental Capacity Act (MCA), however 93% of staff had completed this. We report on concerns about the application of the MCA later in this report.

Staff were also not supported by regular 1-to-1 supervision sessions with senior staff. These were not always held as planned, and due to changes to staff duties there were fewer opportunities to meet.

The provider should also ensure sufficient staff were deployed to meet people’s needs. We heard call bells ringing for more than 10 minutes without being answered and people described feeling they could not ask staff for support as they were busy supporting others. We will also report later about people seldom being offered a bath as staffing did not allow this more frequently.

All feedback received from staff, people, relatives and health and social care professionals reflected that staffing levels were too low at the Lawns.

People and their relatives were mostly satisfied with the cleanliness of the premises and told us they saw staff wearing personal protective equipment (PPE) when working around the service.

Feedback included, “Staff wear aprons, and it’s kept clean.” “The place is spotless, no smell, always see cleaners about. The building and dad’s room are clean.” “It’s clean, no smells and am sure the hygiene is good.” “I see them with gloves, see good practice. Mum’s room is usually clean, smelt once due to old carpet and they put down lino.” “Cleanliness? Not seen as a problem. The room is tidy. Only the usual smells. Everything is quickly mopped away.” “Handwashing? Yes. Yesterday the catheter bag was too tight. A member of staff sorted it and then washed their hands.” “He feels the home is very clean and is happy that they come clean his room every day.” “Infection control? Yes, they wear gloves when they do anything. PPE not during the day.”

Two relatives told us they had a poor experience of hygiene at the Lawns. Their relative slept in their reclining chair and they said, “The bed has become a dumping ground for medical supplies. Dirty clothes are left on the bed. Clean clothes are piled up.”

We did not receive feedback about IPC from staff members however, when we asked if they felt proud to work at the Lawns, a response from 1 staff member began, “I did, but not anymore. Its run down. It’s not clean.”

The premises were quite dated and in need of redecoration looking worn in places. There were housekeeping staff present throughout our inspection. We observed the service was clean and free from malodours. During the site visit we saw cleaning taking place. PPE was available throughout the service, and we observed staff using PPE safely and appropriately. There was a surplus stock of PPE at the premises.

One health and social care professional commented: “I found the cleanliness to be varied, with some rooms being clean and tidy and then others were not.”

The provider had updated their IPC policy in line with government guidance.

IPC audits had been completed monthly and had identified concerns such as curtains and blinds in need of replacement that had been ordered as part of an action plan.

Staff had completed training in IPC, the completion rate was at 93% when we visited. The training was an online course.

People had not always received their medicines in a safe way and in accordance with prescriber’s instructions which placed people at risk of harm. For example, there was no clear written instructions from a medical professional or guidance for staff for administering 1 person’s “when required” antipsychotic medication Lorazepam. 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 medication of people with prescribed antipsychotic medicines.

Relatives told us, “Staff deal with the medication. There is a policy in place. They call me with any changes in prescriptions. Once they gave 1 pill instead of 2. The mistake was sorted straight away. The home called me to let me know” and “My [loved one] has very little medication to take. Staff control it. The process of getting things prescribed is cumbersome. A weekly visit from the nurse practitioner gets things organised.”

Staff told us they felt well supported regarding medicines management, and that they felt that the systems in place worked well. They told us they had training and competency checks to make sure they gave medicines safely.

Comments from staff included, “I have received all my medication training and believe I am compliant with my medication competency” and “All training used to be online but recently we had face-to-face medication training.”

Staff told us that there were not always enough trained staff on duty to administer medicines. “The Lawns appeared to be struggling with their staffing; lots of agency [staff] being used and constantly short staffed and asking for people to help with medication etc. These short staffing levels obviously had an impact on the provision of care for the individuals living there” and “Over the last 8 months I didn't have time to look at any of my other responsibilities as I was covering duty and medication all the time.” Staff described how medicines errors were identified, recorded and followed-up. Where errors or incidents had occurred, these were reported and investigated appropriately.

Medicines were not always managed safely. Risks associated with the use of high-risk medications like anticoagulants or potentially flammable creams and emollients were not always assessed.

Personalised protocols were not in place for some medicines prescribed as ‘when required’ When they were in place they were not always up to date.

People’s medicines were not always stored securely. We found rooms and cupboards were stored unlocked during our site visit. We also found creams left in 1 person’s bedroom. Medicines errors or incidents were reported and investigated. Medicines records showed that they were given as prescribed to people.

We observed staff giving medicines safely and in a kind and caring way, taking time with people, and asking if any ‘when required’ medicines were needed. We observed people’s individual preferences for how they liked to take their medicines were respected by staff.