CQC report explained · a nursing home
What the CQC found at Lukestone Dementia Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Risk assessments and staff guidance were not always detailed, complete or up to date. Medicines were not always managed safely, including one person's prescribed medicine being missed for 14 days.
- Effective?
- Good
- This question was not rated in this focused inspection. Staff told inspectors they did not always have the training or knowledge needed for dementia, distressed behaviour and some complex medical needs.
- Caring?
- Good
- This question was not rated in this focused inspection. Inspectors found that most staff knew people well and that interactions were kind and supportive.
- Responsive?
- Good
- This question was not rated in this focused inspection. Relatives said they had good relationships with the home, but people and relatives were not always involved in care planning or risk assessments.
- Well-led?
- Requires improvement
- Management checks had not identified important safety and record-keeping problems. Records were not always accurate, complete or up to date, and staff concerns were not always known by the registered manager.
What inspectors found, December 2021
Rated Requires Improvement; inspectors found kind care and good infection control, but serious gaps in risk management, medicines and oversight.
This was an unannounced focused inspection on 2 and 3 September 2021. Inspectors followed up concerns about managing risk. They spoke with people, relatives and staff, and checked care records, staff files, medicines information and management records.
The home was not always safe. Risk assessments and guidance were sometimes missing or out of date. One person did not receive prescribed medicine for 14 days. Incidents were not always reviewed well enough to prevent them happening again. Staff also reported that there were not always enough staff or enough training for complex needs and distressed behaviour.
The home was also not always well-led. Audits had failed to find problems with records, risk assessments, falls, wounds and behaviour monitoring. People and relatives were not always involved in care planning. However, inspectors found kind and supportive interactions, good infection control, and generally positive views from people and relatives.
The overall rating was Requires Improvement. Both Safe and Well-led were rated Requires Improvement, having fallen from Good at the previous inspection in 2018. The report says there was limited assurance about safety and an increased risk that people could be harmed.
Kind relationships
Most staff knew people well. Inspectors saw kind and supportive interactions, and people and relatives praised the care.
“It was clear that most staff knew people well. Interactions were kind and supportive and people living at the service and their loved ones praised the care they received.” from the report
Infection control
The home was clean and well maintained. Inspectors found a robust cleaning system and appropriate infection prevention measures.
“The service was clean, well maintained and there was a robust cleaning regime in place.” from the report
Open communication about incidents
Relatives said staff informed them when falls or other concerns happened. Inspectors also found that the manager had undertaken work on being open when things went wrong.
“Relatives felt that staff were open and honest when things went wrong” from the report
Links with health professionals
Staff and the manager had good relationships with several health professionals and regularly sought advice.
“The staff and registered manager had good relationships with healthcare professionals” from the report
Incomplete risk information
seriousSome people did not have detailed or current risk assessments and guidance. This included risks linked to falls, choking and specialist medical needs.
“Risks to people were not always mitigated as the service did not always provide detailed risk assessments and guidance for staff on how to support people with specialist medical needs.” from the report
Missed medicine
seriousOne person did not receive prescribed medicine for 14 days. The report says another route should have been used to obtain the prescription.
“One person had missed their medication to help manage behaviours that challenge for 14 days.” from the report
Staffing and training
needs fixingStaff said there were not always enough staff to observe people safely. Some permanent and agency staff lacked training for complex medical needs and distressed behaviour.
“There is not enough staff to observe people, and that is so important, especially when they are aggressive towards other residents - it is a big risk.” from the report
Weak management checks
needs fixingAudits did not identify problems found by inspectors. Care plans, risk assessments and records about incidents and behaviour were not consistently complete or up to date.
“Audits failed to identify issues found on inspection, such as lack of consistent documentation for risks, falls, wound management and behaviours.” from the report
Limited involvement
needs fixingPeople and relatives were not always involved in care planning or risk assessments. Relatives were not offered access to care records when they asked about medicine changes.
“People and their relatives were not involved in care planning or risk assessments.” from the report
- 01What has changed since the inspection to make sure every person has a current risk assessment with clear guidance for staff?
- 02How do you check that medicines are available and given on time, especially when a person changes doctor's surgery?
- 03How many staff with the right training for dementia, distressed behaviour and complex medical needs are on each shift?
- 04How do you record and review falls, absconding, wounds and distressed behaviour, and how do you check that lessons have been acted on?
- 05How will my relative and our family be involved in care planning, risk assessments and decisions about medicine changes?
This was a focused inspection following concerns about risk management; only Safe and Well-led were rated, while the other key questions were not rated in this report. This explanation was written from the published report of 2 December 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.
What inspectors found, June 2018
Rated Good; inspectors found safe, kind and personalised care, with no serious risks or concerns identified.
Inspectors visited the home without warning on 15 and 16 May 2018. They spoke with people living there, relatives and staff, observed care, reviewed five care records and checked staffing, training and quality records.
They found enough suitably checked staff, safe medicines arrangements and good systems for managing risks, safeguarding people and preventing infection. Staff had the training and skills needed, and people were supported with food, drink and healthcare.
People were treated with kindness, dignity and respect. Care was personalised, families were involved in reviews, activities were available and complaints were recorded and responded to.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. The previous inspection was also Good, and inspectors said the evidence continued to support that rating.
Safe staffing
Inspectors found enough staff to meet people's needs. Recruitment checks were completed before permanent staff worked independently.
“There were enough staff employed to help keep people safe and to meet their needs.” from the report
Safe medicines
Medicines were stored securely, given as prescribed and recorded accurately. Records were audited weekly by senior staff.
“People received their medicines in a safe way.” from the report
Kind and respectful care
Staff were seen supporting people patiently and compassionately, while protecting their dignity and privacy.
“People were treated with kindness, respect and compassion.” from the report
Personalised support
Staff knew people's histories, interests, likes and dislikes, and used this information in day-to-day care.
“Care files had detailed information about their personal histories, including what made the person happy, what upset them and what was important to them.” from the report
Good management checks
The home used audits and other monitoring systems to identify shortfalls and make improvements. People, relatives and staff were involved in developing the service.
“There were systems in place to monitor and assess the service which were used to drive improvement.” from the report
Inspectors raised no specific concerns in this report.
- 01How do you assess and review my relative's risk of falling or other personal risks?
- 02How will you record and review my relative's medicines, including any medicines given covertly?
- 03How will you use my relative's personal history, likes and dislikes in their daily care?
- 04What activities or one-to-one support will be available if my relative does not want to join communal activities?
- 05How will I be involved in care reviews and decisions about end of life care?
This was an unannounced inspection of the overall service, covering all five CQC questions; all five ratings remained Good from the previous inspection. This explanation was written from the published report of 21 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 Lukestone Dementia Nursing Home
3 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- December 2021Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Lukestone Dementia Nursing Home →
- June 2018Goodstayed GoodSafe: GoodWell-led: Good
Read what inspectors found at Lukestone Dementia Nursing Home →
- April 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 18 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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