CQC report explained · a residential care home
What the CQC found at Lindisfarne Care Home Limited
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- Medicines were generally managed safely and staffing levels were sufficient. However, recruitment checks were not always completed before staff worked unsupervised, and some safety checks and medicines competency checks needed improvement.
- Effective?
- Good
- Staff were trained and understood people's needs. People's nutrition and health needs were supported well, although some care plans needed more person-centred information and clearer records about capacity and best-interest decisions.
- Caring?
- Good
- Staff treated people with kindness, compassion, dignity and respect. People were involved in decisions, encouraged to remain independent and supported according to their preferences.
- Responsive?
- Good
- People received personalised care and had a wide range of activities, including individual and community activities. Complaints were recorded and acted on, and people knew how to raise concerns.
- Well-led?
- Good
- The home was organised and had an open, supportive team culture. Audits, meetings and surveys were used to monitor the service and gather people's views.
What inspectors found, May 2019
Lindisfarne Care Home Limited is rated Good overall; inspectors found kind, responsive care, but safety Requires Improvement.
Two inspectors made an unannounced visit on 01 May 2019. They spoke with people living at the home, relatives, staff and a health professional. They reviewed care records, medicines information and other checks on the service.
People and relatives praised the care, staff, meals, cleanliness and homely atmosphere. Inspectors found staff caring and well trained, with good support for people's health, choices, activities and end of life care.
The main concerns were about safety systems. Recruitment checks were not always completed before staff worked unsupervised. Some environmental checks, medicines competency checks and care records also needed improvement.
The overall rating was Good, as were Effective, Caring, Responsive and Well-led. Safe was rated Requires Improvement, meaning some safety arrangements were not always reliable and there was limited assurance about safety.
Kind and respectful care
People described very positive experiences. Inspectors saw staff build warm relationships, listen to people and support their choices and independence.
“We saw staff treat people with kindness and compassion.” from the report
Good health support
Staff understood people's health needs and contacted other services promptly when needs changed. Handover information helped staff provide consistent support.
“We spoke with one health care professional who confirmed there were good relationships with the staff team and support was requested promptly and advice acted upon.” from the report
Food and nutrition
People praised the food and had their nutritional needs monitored. Food could also be prepared outside normal mealtimes.
“Kitchen staff were available from early in the morning until into the evening to ensure people could have food prepared outside mealtimes should they wish.” from the report
Activities and atmosphere
The home offered varied activities suited to people's interests and needs, including group activities, one-to-one support and community outings.
“We saw there was a comprehensive activity programme available to people including in house entertainment and community activities.” from the report
Recruitment checks
seriousOne staff member worked unsupervised before the required DBS check had been checked, and proof of identity was not kept on file. The report says this was an isolated incident, but the provider needed stronger systems to prevent it happening again.
“We identified safe recruitment procedures were not consistently followed.” from the report
Building safety checks
seriousWindow restrictors were not checked regularly and some wardrobes were not attached to the wall. The manager put systems in place after inspectors raised this.
“However, window restrictors were not being checked regularly and not all wardrobes were attached to the wall to reduce the risk of injury.” from the report
Medicines competency checks
needs fixingPeople received their medicines as they should, but checks of staff competence were not being completed in line with best practice. The manager said a new process would be introduced.
“Checks on staff's competence to manage medicines were not being completed in line with best practice guidelines.” from the report
Care records
needs fixingSome care plans did not contain enough detailed, person-centred information. Records also needed to show more clearly how capacity and best-interest decisions had been considered.
“Some care plans would have benefitted from more detailed person-centred information.” from the report
- 01Have all staff recruitment files now been checked for DBS clearance and proof of identity before staff work unsupervised?
- 02How often are window restrictors and wardrobes checked, and can you show us the latest records?
- 03How do you now check that staff remain competent to administer medicines?
- 04Have the care plans been updated with more detailed, person-centred information, including recent changes in people's needs?
- 05How are capacity assessments and best-interest decisions recorded and reviewed?
This was an unannounced inspection that looked at the overall service and all five CQC questions, including records, staff practice, people's experiences and management systems. This explanation was written from the published report of 25 May 2019 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, November 2016
Rated Good; inspectors found safe, caring and well-organised care, with a few minor issues dealt with during or soon after the inspection.
The inspection took place on 1 and 2 September 2016. The first day was unannounced. Inspectors spoke with people living in the home, visitors, staff and a healthcare professional. They also checked care plans, medicines, staff records, complaints, accidents, risk assessments and quality checks.
People said they felt safe and well cared for. Inspectors found enough staff, safe medicines management, suitable recruitment checks and systems to manage risks and safeguarding concerns. The home was clean, and staff were observed to be kind, respectful and attentive.
Care plans were person centred and activities were available. People could see healthcare professionals and were involved in decisions about their care. Inspectors found effective leadership and quality monitoring. A few issues, including some building hazards and areas where care plans needed more detail, were addressed during or shortly after the inspection.
People felt safe
People said they felt safe and well cared for. Staff understood how to report suspected abuse, and safeguarding concerns had been handled appropriately.
“People told us they felt safe and were well cared for.” from the report
Kind and respectful staff
Staff were attentive and supportive. Inspectors saw people being treated politely, with privacy and dignity respected.
“We observed staff members interacted in a caring and respectful manner with people using the service.” from the report
Personalised care
Care plans recorded people’s individual needs, preferences and abilities. Staff were able to explain how they supported each person.
“Care plans were sufficiently detailed to guide staffs' care practice and gave a clear summary about each person and their needs.” from the report
Good healthcare links
People could access healthcare when needed. Inspectors found positive working relationships with healthcare professionals.
“Links with other health care professionals and specialists to help make sure people received appropriate healthcare had been made.” from the report
Activities and involvement
People were offered group and one-to-one activities, trips and opportunities to receive visitors. People and relatives could give feedback and make suggestions.
“The people living at Lindisfarne Care Home Limited accessed activities in the service.” from the report
Staff supervision was not frequent
needs fixingFormal supervision meetings did not happen as often as planned. Staff could seek advice, and the manager said they intended to increase the frequency.
“Formal supervision meetings were not frequently conducted, although staff told us they could seek guidance and advice from the registered manager.” from the report
Some building hazards needed attention
needs fixingSome wardrobes were not secured to walls, and two sash windows had broken cords that could cause finger injuries. The report says action was taken during or soon after the inspection.
“Two sash windows also required attention as the sash cords had snapped, meaning they were heavy to open, could not be held open without being wedged and due to their weight could entrap people's fingers.” from the report
Some care plans needed more detail
minorInspectors advised the home to add clearer guidance where one person could not use their call bell and another had difficulty swallowing. The home dealt with this at the time.
“We provided advice to the registered manager on areas where further detail would be beneficial to improve guidance for staff.” from the report
- 01How often do staff now receive formal supervision meetings, and how is this checked?
- 02Have all wardrobes been secured and have the sash windows been repaired? How are similar hazards identified now?
- 03How are care plans checked to make sure they give enough detail about call bells, swallowing difficulties and other individual risks?
- 04How are people’s medicines reviewed when a Deprivation of Liberty Safeguard has conditions attached?
- 05How are people and relatives involved in reviewing care plans and suggesting improvements?
This was an inspection of the overall service and included all five CQC questions, with the first day unannounced. This explanation was written from the published report of 8 November 2016 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 Lindisfarne Care Home Limited
2 rated inspections over 3 years: the service has held its Good rating throughout.
- May 2019Goodcurrent ratingstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Lindisfarne Care Home Limited →
- November 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Lindisfarne Care Home Limited →
- October 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 12 January 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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