CQC report explained · a nursing home
What the CQC found at Lanercost House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough safely recruited staff, suitable safeguarding arrangements, good infection control and checks on the premises and equipment. They identified medicines documentation issues, unsecured thickeners and some out-of-date evacuation plans.
- Effective?
- Good
- This area was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This area was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This area was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Well-led?
- Good
- Inspectors found an open, positive culture, approachable managers, clear management arrangements and systems for monitoring quality and improving care.
What inspectors found, January 2024
Rated Good; inspectors found safe, kind care, but medicines records and some safety documents needed improvement.
This was an unannounced focused inspection on 5 and 20 December 2023. Inspectors spoke with people, relatives, staff and health professionals. They reviewed care plans, recruitment records, risk assessments, medicines information and management checks.
The home was rated Good overall. Safe and well-led were both rated Good. Inspectors found enough safely recruited staff, good infection control, suitable safeguarding arrangements and a caring, open management culture.
There were some problems with medicines documentation, the secure storage of thickeners and some personal emergency evacuation plans. These issues were addressed during or after the inspection. The CQC made one recommendation to review medicines procedures.
This was not a full inspection of all five areas. The ratings for Effective, Caring and Responsive were carried over from the previous comprehensive inspection, which was published in June 2018.
Kind and respectful staff
Inspectors found good relationships between staff and people. Relatives described the staff and managers as kind and supportive.
“Staff were respectful and kind towards people, relatives, and each other.” from the report
Staffing and recruitment
Inspectors found enough suitable staff and safe recruitment checks, including references and DBS checks.
“The provider ensured there were sufficient numbers of suitable staff.” from the report
Clean environment
The home was clean and tidy. Staff had infection control training and enough protective equipment.
“The home was clean and tidy with no malodor.” from the report
Open management
The management team was approachable and had systems to monitor care, learn from incidents and involve people, relatives and staff.
“There was a positive and open culture at the service.” from the report
Medicines records
needs fixingInspectors found problems with medicines documentation, including records for as-required medicines and creams or lotions. The records were reviewed and updated after feedback, but the CQC recommended further review of medicines procedures.
“We found some issues with the completion of medicines documentation.” from the report
Some safety documents needed updating
needs fixingThickeners for people with swallowing difficulties were not always stored securely. Some personal emergency evacuation plans were not up to date. Both issues were addressed during the inspection process.
“Personal emergency evacuation plans held centrally (which would be given to the fire service in the event of an evacuation) were not all up to date.” from the report
Refurbishment still underway
minorA significant refurbishment programme was in progress, with one further unit due to be decorated and modernised. Families may want to ask what work remains.
“A significant refurbishment programme was underway with a further unit to be fully decorated and modernised in the early new year.” from the report
- 01What changes have been made to medicines records since the inspection, especially for as-required medicines and creams or lotions?
- 02How do you now check that thickeners are stored securely?
- 03How often are personal emergency evacuation plans checked, and are all of them currently up to date?
- 04What refurbishment work is still outstanding, and how could it affect residents?
- 05What are the current ratings or most recent evidence for Effective, Caring and Responsive, as these areas were not assessed in this inspection?
This was an unannounced focused inspection of Safe and Well-led only; the other ratings were carried over from the previous comprehensive inspection published in 2018. This explanation was written from the published report of 11 January 2024 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, June 2018
Rated Good; inspectors found safe, kind and well-organised care, with staffing deployment and activities still being developed.
This was an unannounced inspection on 2 and 3 May 2018. The inspectors observed care, spoke with people, relatives and staff, and reviewed care records, training records, equipment checks and other documents.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found suitable safeguarding, recruitment, medicines and risk management arrangements. They also found kind care, good support with food and health needs, and care plans that reflected people's preferences.
The home was looking at how to deploy staff more effectively between its units. It also wanted to broaden activities and involve the local community more. The overall Good rating was unchanged from the previous inspection in November 2015.
Kind and respectful care
Inspectors saw staff giving patient, suitable support. People and relatives spoke positively about staff, and privacy and dignity were maintained.
“We observed kind, patient and suitable support being provided.” from the report
Personal care planning
People, relatives or advocates were involved in care planning. Plans recorded people's needs, abilities, preferences and the support required.
“The management team had ensured the plans reflected the person centred care that was being delivered.” from the report
Good support with food and health
Meals were nutritionally balanced and adapted to people's needs. People were supported to attend health appointments and receive specialist advice when needed.
“We saw everyone had support plans relating to food and fluid.” from the report
Quality monitoring
The management team carried out checks on care planning, medicines and health and safety. Records, complaints and incidents were reviewed to look for patterns and improvements.
“This helped the registered manager to monitor the quality of the service provided.” from the report
Staff deployment between units
needs fixingStaffing levels on each unit were identical, even though the units supported people with different needs. The manager began reviewing deployment during the inspection and trialled new shift times.
“However we did note that staffing levels on each unit were identical, which meant either the service was clear that people living with dementia had identical needs to people who were frail and elderly or staff were being deployed incorrectly.” from the report
Activities and community links
minorActivities were available, including quizzes, painting and entertainment. The home said it wanted to develop a broader range of activities involving the local community.
“The service intended to develop in this area and create a broader range of activities that involved the local community in which it was situated.” from the report
- 01How are staff now deployed between the units, particularly for people living with dementia and people who are frail or elderly?
- 02What changes were made after the review of staffing deployment and the trial of new shift times?
- 03What broader activities and community links have been introduced since the inspection?
- 04How are people and their families involved in reviewing and updating care plans?
- 05How are medicines reviews and staff medicines competencies kept up to date?
This was an unannounced inspection of the whole service, including all five rating areas, and the overall Good rating was unchanged from November 2015. This explanation was written from the published report of 26 June 2018 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Lanercost House
3 rated inspections over 8 years: the service has held its Good rating throughout.
- January 2024Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2018Goodstayed GoodSafe: GoodWell-led: Good
- March 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2014
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- February 2011
Registered with the Care Quality Commission on 15 February 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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