CQC report explained · a nursing home
What the CQC found at Lyndale Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found improved safety checks, fire training, risk management, safeguarding and medicines systems. Infection prevention arrangements were also found to be suitable.
- Effective?
- Good
- This focused inspection did not give a new rating for Effective.
- Caring?
- Good
- This focused inspection did not give a new rating for Caring, although inspectors observed compassionate and respectful care.
- Responsive?
- Good
- This focused inspection did not give a new rating for Responsive. Inspectors did find that people's choices, activities and individual needs were considered.
- Well-led?
- Good
- Inspectors found stronger governance, accurate care records, an open management style and good communication with people, relatives and staff.
What inspectors found, March 2023
Lyndale Nursing Home is rated Good; inspectors found safer care and stronger management after earlier problems.
This was an unannounced focused inspection on 16 February 2023. One inspector visited the home, observed care, spoke with people, relatives and staff, and checked care plans, medicines records, training and quality records.
The home was rated Good for Safe and Well-led. Inspectors found that safety checks, fire training, medicines arrangements, safeguarding systems and care records had improved. They also found kind, person-centred care and good involvement of people and relatives.
The previous rating was Requires Improvement, published on 26 August 2022. The home had previously breached Regulation 12, but inspectors found enough improvement had been made and the provider was no longer in breach.
Improved safety checks
Environmental checks were better recorded, fire training had been completed and risks to people were identified and managed.
“Health and safety checks of the environment were now better recorded.” from the report
Safe medicines practice
Medicines were administered by trained nurses. Guidance for as-needed medicines had been added and records were accurate.
“Medicines administration records (MAR) had been completed accurately.” from the report
Kind and respectful care
People and relatives described staff as caring and kind. Inspectors observed care that was compassionate, dignified and respectful.
“We observed staff support people in a person centred and compassionate way which was dignified and respectful.” from the report
Responsive management
The manager welcomed feedback and acted on people's wishes, including arranging regular access to books and supporting social activities outside the home.
“We saw how feedback from people had been welcomed and acted on in a proactive and engaging way.” from the report
Improvement since the last inspection
The provider had acted on the previous inspection findings. The home was no longer in breach of the regulations.
“At this inspection we found improvements had been made and the provider was no longer in breach of regulations.” from the report
Some policies were still out of date
minorNot all policies and procedures had been updated when inspectors visited. An action was in place to address this in the near future.
“Although not all policies and procedures had been updated, an action was in place to have this resolved in the near future.” from the report
- 01Have all the policies and procedures that were out of date at the inspection now been updated?
- 02How will safety checks continue while the maintenance person is replaced?
- 03Can you show me how as-needed medicines are managed and how staff know when to give them?
- 04How are care records checked to make sure important care, such as repositioning, is recorded accurately?
- 05Which ratings from the previous comprehensive inspection still apply to Effective, Caring and Responsive?
This was an unannounced focused inspection of Safe and Well-led, including infection prevention and control; it did not give new ratings for Effective, Caring or Responsive. This explanation was written from the published report of 11 March 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, August 2022
Rated Requires Improvement; inspectors found caring staff and effective support, but safety checks and care records were not always reliable.
This was an unannounced focused inspection on 26 July 2022. Inspectors looked at Safe, Effective and Well-led. They spoke with people, relatives and staff, observed care, checked the home, medicines, staff records and care records, and followed up after the visit.
The home was rated Requires Improvement overall. Safe and Well-led were rated Requires Improvement, while Effective remained Good. Inspectors found that people were generally protected from risks, received kind care and had their health needs supported, but some environmental safety checks, training records, policies and care records were not consistently completed.
The home had a new registered manager who had already identified many of the problems and had plans to address them. However, the inspection found a breach of Regulation 12 because safety systems were not consistently used. The previous overall rating was Good in March 2018, so the overall rating has gone down.
Kind and respectful care
Inspectors saw compassionate, person-centred care. People and relatives described the home as safe, caring and homely.
“It's not just for show here, it's genuinely caring care, the gold standard, it's exactly what a care home should be, caring and a real home from home.” from the report
Good healthcare support
The home worked with external health professionals and made referrals when people's needs changed. Inspectors saw staff supporting someone with a hospital appointment.
“The service worked in collaboration with appropriate services to meet people's needs.” from the report
Infection control
The home was clean and staff followed infection prevention procedures. Visiting was supported and visitors were made welcome.
“The service was clean and well maintained.” from the report
Missed safety checks
seriousSome routine checks of fire safety, window restrictors and water temperatures were not always carried out. Inspectors said this created a risk that safety improvements could be missed.
“However, more routine checks such as some fire safety checks, window restrictors and water temperature checks in people's room were not always being undertaken.” from the report
Incomplete care records
needs fixingRecords did not always accurately show the care people had received. This included records about repositioning and specialist food and drinks.
“People's care records did not always properly evidence the care and support that had been given.” from the report
Out-of-date training
needs fixingSome staff had not completed refresher training in areas including health and safety and fire awareness. The manager had identified this and arranged further training.
“Although the staff training matrix showed that some training was out of date, (health and safety and fire training) staff were experienced and had the right skills to carry out their roles.” from the report
Weaknesses in policies and oversight
needs fixingSome policies had not been reviewed since 2017, and a safeguarding policy was initially missing. The manager put a safeguarding policy in place by the end of the inspection process.
“Although policies and procedures were in place, some had not been reviewed since 2017 and we could not locate an up to date safeguarding policy.” from the report
- 01Have all routine fire safety, window restrictor and water temperature checks now been completed and recorded?
- 02What evidence can you show that staff have completed refresher fire and health and safety training?
- 03How do you now check that repositioning, thickened drinks and pureed meals are recorded accurately and at the time care is given?
- 04Have all policies been reviewed and kept up to date, including the safeguarding policy?
- 05What progress has been made on the action plan requested by CQC for the Regulation 12 breach?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected during this visit, and ratings for uninspected questions carried over from the previous inspection. This explanation was written from the published report of 26 August 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 Lyndale Nursing Home
4 rated inspections over 7 years: the service has held its Good rating throughout.
- March 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2022Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- March 2018Goodstayed GoodSafe: GoodEffective: GoodWell-led: Good
- February 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2014
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 21 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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