CQC report explained · a residential care home
What the CQC found at Lyndhurst Residential Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Risks were assessed and plans were in place to manage them. Inspectors also found safe medicines systems, enough staff and suitable safeguarding arrangements.
- Effective?
- Good
- Staff had the skills and knowledge to meet people's needs. People's dietary needs, legal rights and access to health professionals were supported.
- Caring?
- Good
- Staff treated people with dignity and respect. People and relatives were involved in care planning and reviews.
- Responsive?
- Good
- People were supported with activities that interested them and care plans gave staff detailed guidance. The home had a complaints process and relatives felt able to raise concerns.
- Well-led?
- Requires improvement
- The new manager had introduced better monitoring and encouraged people, relatives and staff to contribute. CQC wanted to be satisfied that these improvements would continue.
What inspectors found, March 2018
Rated Good overall; care was safe, kind and responsive, but well-led was rated Requires Improvement while improvements were being sustained.
Inspectors made an unannounced visit on 20 February 2018. They spoke with people, relatives, staff and the manager. They also checked care files, staff records and other management records.
The home was rated Good for safe, effective, caring and responsive care. Inspectors found that risks were assessed, medicines were managed safely, staff had suitable training, and people received respectful and personalised support.
Well-led was rated Requires Improvement. The new manager had made significant improvements and introduced better monitoring, but CQC wanted to see that these changes continued. The home had been rated Requires Improvement overall and Inadequate for well-led at the previous inspection in June 2017.
Up-to-date care plans
Care plans reflected people's choices and included guidance for managing identified risks and changing needs.
“Care plans were accurate and up to date.” from the report
Activities and wellbeing
The home had added a wellbeing role and people took part in activities such as gardening, knitting and painting.
“People were supported to engage in activities that interested them.” from the report
Safe systems
The home had systems for managing risks, medicines, safeguarding, staffing, equipment and infection control.
“People were kept safe through systems that ensured the environment and equipment were well maintained.” from the report
Provider actions not always completed
minorThe manager had identified actions needed from the provider, but these were not always completed. One example was an outdated statement of purpose.
“where the registered manager had identified actions needed by the provider these had not always been completed.” from the report
Well-led improvements need to last
needs fixingThe manager had made major improvements, but CQC kept the well-led rating at Requires Improvement because it needed to see that the changes were sustained.
“Therefore, we need to be satisfied that these changes are being sustained.” from the report
- 01What changes have been made since the inspection to make sure provider actions are completed on time?
- 02How do you check that improvements in care planning and activities are continuing?
- 03What was done about the missing signature found on a medicine administration record?
- 04How are people and relatives involved in reviewing care plans and suggesting improvements?
- 05How will you show CQC that the well-led improvements have been sustained?
This was an unannounced inspection covering all five CQC key questions; the previous inspection was in June 2017, when the home was rated Requires Improvement overall and Inadequate for well-led. This explanation was written from the published report of 17 March 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.
What inspectors found, November 2017
Lyndhurst Residential Care Home was rated Requires Improvement; inspectors found kind care but gaps in risk management, activities and leadership.
Inspectors visited the home without notice on 28 June 2017. They spoke with people, relatives, staff and a health professional. They looked at care records, medicines records, staff files and management records, and observed care.
The home was rated Good for effective care and caring. People were supported by trained staff who were kind, respectful and compassionate. Medicines were generally managed safely, and people were supported to access health professionals when needed.
The home was rated Requires Improvement for safe care and responsive care. Some risks, including falls, did not have clear management plans. Care plans were incomplete or out of date, and people did not always have activities that interested them or support to go out.
The home was rated Inadequate for being well-led. Quality checks had not led to lasting improvements, despite concerns going back to 2012 and a previous warning notice. The overall rating was Requires Improvement, and the CQC imposed conditions requiring monthly reports.
Kind and respectful care
People and relatives described staff as caring and helpful. Inspectors saw staff offer empathy, reassurance and respect during personal care and difficult moments.
“Throughout the inspection we saw staff supporting people in a caring manner.” from the report
Medicines generally managed safely
Medicines were stored securely and records were accurate. Staff had training and their competence was checked before they worked unsupervised.
“Medicines were managed safely.” from the report
Trained and supported staff
Staff received an induction, training and regular supervision. They said they could approach managers for help and felt listened to.
“Staff completed training to ensure they had the skills and knowledge to meet people's needs.” from the report
People involved in care
People were involved in decisions about their care, and relatives were involved in care planning where appropriate. People knew how to complain and felt confident raising concerns.
“People were involved in their care and were confident to raise concerns with the management of the service.” from the report
Risks were not always managed
seriousSome risk records were incomplete or out of date. One person had falls but there was no clear plan for staff to follow and no evidence of action after the incidents.
“We could not be sure the risk to the person of further falls was being appropriately managed.” from the report
Limited activities and outings
needs fixingPeople did not always have activities that interested them. There was no evidence that people had been supported to go out unless family or visitors took them.
“People still did not always have access to activities that interested them and did not have the opportunity to go out of the service.” from the report
Care plans were incomplete or inaccurate
seriousTwo newer residents did not have completed care plans. Other plans contained information that no longer reflected people's needs, so staff might not have had reliable guidance.
“People's care plans were not always fully completed to ensure staff had sufficient information to meet people's needs.” from the report
Weak quality monitoring
seriousAudits and other checks had not led to effective improvement. They missed problems with care plans and did not ensure that actions about activities and safety were completed.
“The provider did not have effective systems to monitor and improve the quality of the service.” from the report
- 01What has changed in the care planning process since this inspection, and how do you check that plans are complete and up to date?
- 02How would you manage my relative's specific risks, including falls, and how would you review the plan after an incident?
- 03What regular activities and opportunities to go out are available, and how are they matched to each person's interests?
- 04What improvements were included in the monthly reports required by the CQC, and what evidence shows that these improvements have lasted?
- 05How do you check that audits identify problems and that agreed actions are actually completed?
This was an unannounced comprehensive inspection covering all five key questions, with the inspection visit taking place on 28 June 2017. This explanation was written from the published report of 11 November 2017 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 Lyndhurst Residential Care Home
4 rated inspections over 2 years: the service has improved, from Requires improvement to Good.
- March 2018Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Lyndhurst Residential Care Home →
- November 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Inadequate
Read what inspectors found at Lyndhurst Residential Care Home →
- November 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- October 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- June 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- May 2011
Registered with the Care Quality Commission on 18 May 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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