CQC report explained · a residential care home
What the CQC found at Lansdowne Road (67-71)
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, October 2023
Lansdowne Road (67-71) is Requires Improvement; inspectors found kind, person-centred support but risks, medicines procedures and quality checks were not managed consistently.
This was an unannounced focused inspection on 19 and 20 September 2023. Inspectors spoke with 7 people, 13 staff, relatives and professionals. They reviewed care plans, risk assessments, medicines records, staff files, training, audits and the building.
The home was rated Requires Improvement overall. Safe and Well-led were both rated Requires Improvement. Inspectors found that staff did not always follow guidance about known risks, including medicines and choking. Medicines storage temperatures were not consistently checked, and incident reviews did not always lead to learning.
Inspectors also found positive care. People were supported to be active and independent, staff knew people's needs, and there were enough staff. The registered manager took some immediate actions, but the provider must improve its oversight and send CQC an action plan.
Enough staff
Inspectors found enough staff were deployed to meet people's needs and keep them safe. Recruitment checks were completed before staff started work.
“The service had enough staff deployed to meet people's individual needs and keep them safe.” from the report
Person-centred support
People were supported to be active, make plans and build independence. Staff knew people's individual needs and helped people pursue work, college and community activities.
“People were supported to lead active and fulfilling lives, there was a person centred approach, independence was promoted, and staff supported people effectively to achieve positive outcomes.” from the report
Positive relationships
People, relatives and professionals gave positive feedback about staff. Inspectors saw staff supporting people effectively and found the manager knew people's needs well.
“People, relatives, and external professionals provided positive feedback on the staff's approach to care and support.” from the report
Open management response
The registered manager was open during the inspection and took immediate action in response to some findings. People and staff could approach the manager.
“The registered manager was open and honest during the inspection and showed a commitment in making improvements and took immediate actions in response to our findings.” from the report
Risk guidance was not followed
seriousStaff did not consistently follow guidance for known risks. This included guidance for refused medicines and a modified diet for someone at risk of choking, increasing the risk of harm.
“Staff did not consistently follow guidance provided by the registered manager in how to manage and mitigate known risks to people.” from the report
Medicines checks
seriousStaff did not always follow the agreed steps when people refused medicines. Medicine storage temperatures were also not consistently monitored, despite this having been identified in internal audits.
“The storage temperature of medicines was found to not be consistently monitored.” from the report
Weak quality monitoring
seriousThe provider's checks did not identify or correct all the problems found by inspectors. An internal action plan had been signed off even though further improvements were still needed.
“The systems and processes that assessed, monitored and mitigated quality and safety were not fully effective.” from the report
Incident learning
needs fixingStaff debrief meetings after incidents were not happening routinely. Incident analysis was limited, reducing opportunities to identify patterns and prevent similar incidents.
“However, these meetings were not routinely happening, therefore impacting on the potential for learning.” from the report
Environment and communication
needs fixingSome toilet and shower areas needed refurbishment and more attention was needed to odours. Communication between staff was not always effective, and some records did not show clearly what action had been taken.
“Although the environment's general appearance was clean, improvements were required.” from the report
- 01What has changed to ensure staff follow the guidance when someone refuses medicines?
- 02How are medicine storage temperatures now checked and reviewed?
- 03How do you make sure modified diets and other choking-risk guidance are followed at every meal?
- 04How are incident debriefs and analysis being completed so that learning is acted on?
- 05What checks now show that the action plan is genuinely completed and that improvements are being sustained?
This was a focused inspection of Safe and Well-led only; the other three key-question ratings were not assessed in this inspection, and the previous overall rating was Good. This explanation was written from the published report of 10 October 2023 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, March 2022
Inspected but not rated; inspectors found good COVID-19 infection control and visiting arrangements, with some cleaning practices needing improvement.
This was an unannounced, targeted inspection on 4 February 2022. Inspectors looked mainly at infection prevention and control, visiting arrangements and whether COVID-19 staffing pressures affected people.
Inspectors were assured that the home was using personal protective equipment safely, supporting testing and vaccination, managing visitors and helping people isolate when needed. People were supported to keep in touch with family, friends and advocates through different types of visits and communication.
The home had cleaning schedules and risk assessments. Inspectors discussed keeping hand sanitiser and paper towels replenished and using pedal bins to reduce cross-contamination. The report says action was taken to improve this. The service was inspected but not rated, so this report does not give a standard overall rating.
Keeping in touch
People were supported to maintain contact with friends, families and advocates through face-to-face, window and remote visits.
“People had been supported to maintain contact with friends, families and advocates during the pandemic.” from the report
Visitor safety
Visitors were screened and tested, and staff and visitors used protective equipment and hand hygiene measures.
“The provider ensured visitors to the service provided a negative COVID-19 test result and had their temperature taken” from the report
Infection control
Inspectors were assured that the home was managing infection risks, including testing, PPE, isolation and outbreak prevention.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Staff support
Staff received infection control training and updates, alongside meetings, supervision and access to wellbeing support.
“The registered manager and provider supported staff through regular staff meetings, supervision and an employee assisted well being service was available.” from the report
Cleaning supplies and bins
needs fixingInspectors asked the home to improve the regular replenishment of hand sanitiser and paper towels and to use pedal bins to reduce cross-contamination. The report says action was taken.
“We discussed the cleaning practice at the service to ensure products such as hand sanitiser and paper towels were replenished regularly and how pedal bins were required” from the report
- 01What changes were made after the inspection to keep hand sanitiser and paper towels replenished?
- 02Are pedal bins now used where inspectors said they were required to reduce cross-contamination?
- 03How are visitors currently screened, tested and supported to follow infection control arrangements?
- 04How does the home currently manage staffing pressures linked to COVID-19?
- 05How can people living here keep in contact with family, friends and advocates?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19 staffing pressures; it was not a full rated inspection and the other key questions were not rated. This explanation was written from the published report of 12 March 2022 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 Lansdowne Road (67-71)
3 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- October 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2022Inspected but not ratedSafe: Inspected but not rated
- September 2020Inspected but not ratedSafe: Inspected but not rated
- March 2018Goodstayed GoodSafe: GoodWell-led: Good
- October 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- May 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 10 December 2010.
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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