Lynden Hill Clinic

The provider was in breach of the legal regulations relating to safeguarding, staff recruitment, notification of reportable events and good governance. The provider and the registered manager did not demonstrate they had robust quality assurance systems and governance processes which operated across all levels of the service.. The registered manager did not ensure there was a good learning culture. People could raise concerns or complaints, however these were not always encouraged, listened to or relevant action taken in line with the provider’s policy and procedures. People were not always protected and kept safe. The registered manager did not ensure safeguarding procedures were followed and any allegations or incidents were reported to external agencies accordingly. The registered manager did not ensure they and the staff team consistently understood and managed risks to people’s health and welfare or that staff received consistent training and regular appraisals to maintain high-quality care. The registered manager did not always ensure there were enough staff with the right skills, qualifications and experience as they did not have oversight of staff’s training and support needs. Effective recruitment processes were not in place to ensure, as far as possible, that people were protected from unsuitable persons being employed. Management of medicines and premises was not always safe and not supported with consistent clear records. Staff did not always work well in partnership with other agencies such as GPs, pharmacies and other clinicians to promote and achieve positive outcomes for people. People and staff were not always encouraged to be actively involved in the development and continuous improvement of the service. CCTV was in use at the exterior entrance and communal areas but without an impact assessment on people’s privacy or clear policy on how to manage it.

Staff ensured people were protected from the risk of acquiring an infection during the provision of their care. The facilities and equipment were clean and well-maintained for infection risks to be mitigated. Staff supported people to access physiotherapy and worked well towards rehabilitation goals to improve mobility and confidence.