CQC report explained · a nursing home
What the CQC found at Lindisfarne House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Risks were assessed and managed, staff understood safeguarding, medicines were generally managed safely and the environment was clean and well maintained. Inspectors noted some medicine-recording shortfalls and masks being worn incorrectly by some auxiliary staff.
- Effective?
- Good
- People's needs were assessed, staff were trained and people were supported with food, drink and healthcare. Some care records were generic, and it was initially difficult to track all actions for one person who had lost significant weight.
- Caring?
- Good
- Staff were kind, patient and respectful. Inspectors saw staff supporting people's privacy, dignity, independence and day-to-day choices.
- Responsive?
- Good
- People had personalised care plans and regular activities. Staff worked hard to support visits and video calls, although some daily notes were unclear and some do-not-attempt-resuscitation records needed review.
- Well-led?
- Requires improvement
- The management team promoted a positive culture and responded openly to feedback. However, audits did not always identify problems in records, medicines practice and do-not-attempt-resuscitation documentation.
What inspectors found, February 2022
Rated Good overall; inspectors found safe, kind and responsive care, but the home was not always well-led.
Inspectors made an unannounced visit on 14 December 2021. They spoke with relatives and staff, observed care, and checked care plans, medicines, recruitment files and management records. They also contacted relatives after the visit.
The home was rated Good for safe, effective, caring and responsive care. Inspectors found people were kept safe, received their medicines, had access to activities and were treated with kindness and respect.
The well-led rating fell from Good to Requires Improvement. Audits had not always found gaps in medicine records, do-not-attempt-resuscitation records and other care records. The provider was asked to improve its auditing, although inspectors found no immediate impact on people's health and wellbeing.
Safe care
Inspectors found that risks were assessed and managed, staff understood people's needs and call bells were answered promptly. Relatives generally felt there were enough staff, although one relative said staff were rushed.
“Risks to people's health and safety were assessed, reviewed and managed in line with care plans.” from the report
Kind and respectful staff
Staff were patient and gentle. They supported people's privacy, dignity, independence and personal choices.
“Staff were kind and patient with people.” from the report
Activities and family contact
The home provided activities every day and worked to keep people in contact with relatives despite changing pandemic guidance.
“People were encouraged and supported to take part in activities on a daily basis.” from the report
Good healthcare support
Staff monitored people's health and worked with outside healthcare professionals. Relatives said people could see a GP when needed.
“External professionals confirmed staff worked with them openly.” from the report
Audits missed problems
needs fixingChecks did not always identify gaps in records, medicine administration practice and do-not-attempt-resuscitation documentation. The provider was asked to review its auditing systems and responsibilities.
“Auditing systems and processes did not always identify areas where improvements were required.” from the report
Some records were unclear or incomplete
needs fixingSome daily notes were difficult to follow, and some care records were generic rather than fully person-centred. The provider said these areas would be reviewed.
“At times these daily notes were difficult to follow due to the paperwork itself being unclear in terms of dates and times.” from the report
Infection-control practice
needs fixingSome auxiliary staff were seen wearing masks under their chins. The provider said it would remind staff about correct mask use and added extra checks.
“We observed some instances of auxiliary staff with masks under chins” from the report
Staffing pressure
minorThe home had recently relied on agency staff because of staff self-isolation and recruitment difficulties. One relative felt staff were rushed off their feet.
“The registered manager and area support manager acknowledged a recent reliance on agency staff” from the report
- 01What changes have been made to auditing since inspectors found that audits missed gaps in records and medicines practice?
- 02How do you check that medicine records have complete signatures and that fridge temperatures are recorded?
- 03How are do-not-attempt-resuscitation records reviewed with the relevant healthcare professionals?
- 04How do you make sure agency and auxiliary staff use personal protective equipment correctly?
- 05What is the current balance of permanent and agency staff, and how do you ensure agency staff know each person's needs?
This was an unannounced inspection covering all five key questions, including infection prevention and control; the inspection was also part of a random check of services previously rated Good or Outstanding. This explanation was written from the published report of 3 February 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.
What inspectors found, February 2021
Inspected but not rated; inspectors were assured about infection prevention and control during a targeted COVID-19 review.
Inspectors visited on 27 January 2021. The visit was announced and focused on infection prevention and control practices and staffing.
They found good arrangements for visitors, including temperature checks, questions before entry, personal protective equipment and handwashing facilities. They were also assured that shielding, social distancing, testing, cleaning and outbreak arrangements were being managed.
The home was not given an overall quality rating. Safe was recorded as inspected but not rated, and the report does not give ratings for the other four areas.
Visitor safety checks
Visitors had temperature checks and answered questions before entering. PPE and handwashing facilities were available.
“All visitors had to undergo a temperature check and answer a range of relevant questions before entry.” from the report
Infection control
Inspectors were assured that the home was using PPE safely, following social distancing and shielding rules, and managing infection risks.
“We were assured that the provider was using PPE effectively and safely.” from the report
Continuity of staff
No agency staff had been used at the time of the inspection. The report linked this with better continuity of care and a lower transmission risk.
“The service had not used any agency staff, meaning people received a better continuity of care and the risk of transmission was reduced.” from the report
Family visiting
An outdoor visiting pod had been installed so relatives could see people regularly when visits were possible.
“The provider had installed an outdoor visiting pod so relatives could see their loved ones regularly, when the service was able to.” from the report
Inspectors raised no specific concerns in this report.
- 01Are visitor temperature checks and health questions still carried out before entry?
- 02How do you make sure PPE is available and used safely by staff and visitors?
- 03Are you still avoiding agency staff, and how do you maintain continuity of care?
- 04How are visits through the outdoor visiting pod arranged now?
- 05How are testing, cleaning and outbreak arrangements being managed currently?
This was a targeted inspection of infection prevention and control practices and staffing; the service was inspected but not rated. This explanation was written from the published report of 17 February 2021 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 House
5 rated inspections over 7 years: the service has improved, from Requires improvement to Good.
- February 2022Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2021Inspected but not ratedSafe: Inspected but not rated
- December 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2016Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- September 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- June 2011
Registered with the Care Quality Commission on 9 June 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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