CQC report explained · a residential care home
What the CQC found at Lyndhurst Residential Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, December 2021
Rated Requires Improvement; inspectors found kind and safe day-to-day care, but records, repairs and quality checks still needed work.
This was an unannounced focused inspection on 14 October 2021. CQC looked only at Safe and Well-led because it had received concerns about safety, maintenance and cleanliness. One inspector spoke with people, relatives and staff, observed care, and checked care, medicine, recruitment and management records.
People told inspectors they felt safe and that staff were available, kind and quick to respond. Medicines were handled safely. The home was clean, infection control arrangements were in place, and staff understood safeguarding responsibilities.
Some care risk records did not contain enough detail. Some areas needed redecoration or upgrading, and minor repairs had not been found through the home's own checks. Quality systems had improved but had not yet found or dealt with every issue.
The overall rating stayed Requires Improvement. Safe and Well-led were both rated Requires Improvement. The report says improvements since the previous inspection meant the provider was no longer in breach of regulations, but more work was needed.
Kind staff
People described staff as friendly, kind and familiar with their needs. Inspectors saw kind interactions throughout the day.
“There was a kind and caring culture amongst staff at the home.” from the report
Staff available
People said there were enough staff, and inspectors saw staff around the home. Call bells were answered promptly.
“Staff were visible around the home throughout our inspection and any call bells were answered promptly.” from the report
Infection control
The home had cleaning arrangements, appropriate protective equipment and COVID-19 testing and vaccination support.
“Staff followed the relevant guidance and best practice in relation to infection prevention and control.” from the report
Improvements made
The provider had made progress since the previous inspection, including work on windows and fire doors. Earlier breaches were no longer in place at this inspection.
“The provider had started a wide-ranging schedule of improvement works at the home since our last inspection” from the report
Risk records lacked detail
needs fixingCare plans gave staff basic safety information, but some records were not detailed or robust enough. This could make it harder to understand people's risks fully.
“However, we found the level of detail and robustness of some of these records required improvement.” from the report
Repairs and decoration
needs fixingSome areas still needed redecoration or upgrading. Minor repairs had not been identified through the home's own checks, although the provider completed them during or soon after the inspection.
“Some areas of the home required redecoration and/or upgrading.” from the report
Quality checks not complete
needs fixingManagement checks had improved but had not found or dealt with every issue inspectors identified. The improvements still needed to become consistent and lasting.
“some of the issues we identified during this inspection still had not been identified or addressed by the provider's own quality processes.” from the report
- 01How have you added detail and robustness to people's risk assessments and care records?
- 02Which redecoration, upgrading and repair works are still outstanding, and when will they be completed?
- 03How do your quality checks now make sure that issues are found and dealt with promptly?
- 04How will you show that the improvements made since the previous inspection are being sustained?
- 05What is the current rating for Effective, Caring and Responsive from the previous comprehensive inspection?
This was a focused inspection of Safe and Well-led only; the other key questions were not inspected and their previous ratings were used in calculating the overall rating. This explanation was written from the published report of 15 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, November 2020
Rated Requires Improvement; inspectors found risks from poor incident monitoring, unsafe fire doors and weak management oversight.
The inspection was unannounced and took place on 03 November 2020. Inspectors spoke with one person, staff and relatives. They reviewed care, medicine, recruitment and management records.
The home was not always safe. Fire doors did not work properly in some areas, accidents and incidents were not analysed well, and some parts of the building needed repair. There were enough staff, recruitment checks were safe and infection control arrangements were suitable.
The home was also not always well-led. Managers had not identified or acted on important risks, and had not properly notified CQC about a serious incident. The overall rating fell from Good at the previous inspection to Requires Improvement.
Enough staff
Inspectors found enough staff to meet people's care and support needs. Recruitment checks were also completed safely.
“There were enough numbers of staff on duty to meet people's care needs.” from the report
Safe medicines practice
Medicines were administered by trained staff and were generally managed safely. Inspectors noted that some PRN guidance needed more detail.
“Medicines were managed safely and administered by staff who were trained to do so.” from the report
Positive care feedback
People and relatives spoke positively about the staff and the care provided. Relatives also said they were kept updated during lockdown.
“It feels like home, the staff are lovely and know me well. I have everything I need.” from the report
Fire safety risks
seriousSeveral fire doors did not close properly and some lacked adequate smoke seals. Inspectors referred these concerns to the local fire inspection service.
“Environmental checks had not identified that several fire doors, including those situated in high risk areas such as corridors near to the laundry room and people's bedrooms, did not close to the rebate.” from the report
Incidents not properly reviewed
seriousAccidents and incidents were not recorded or analysed well enough to identify patterns and prevent further harm. This included insufficient information about a specific serious incident.
“The recording of the specific incident was insufficient and did not include any details as to the circumstances of the incident or what injuries the person sustained.” from the report
Weak management checks
needs fixingAudits had not identified unsafe fire doors, repairs needed in the building or repeated unwitnessed night-time falls. The systems did not give enough assurance that risks were being managed.
“Systems and processes did not always operate effectively to prevent harm to people.” from the report
Privacy and building repairs
needs fixingCommunal toilets and bathrooms had no locks, which inspectors said severely affected privacy and dignity. Some facilities were tired or damaged, including a cracked toilet cistern and seat.
“Communal toilets and bathrooms did not have locks. This meant that people's dignity and privacy were severely compromised.” from the report
Serious incident not notified
seriousManagers did not notify CQC about the specific incident in line with regulatory requirements. Their internal investigation was also not completed at the time of inspection.
“The provider failed to notify CQC of circumstances of the specific incident in line with their regulatory requirements.” from the report
- 01Have all the fire doors and smoke seals identified in the report now been repaired and checked?
- 02How are accidents, falls and other incidents now recorded, reviewed and used to prevent repeat harm?
- 03What has changed to make sure serious incidents are reported to CQC and investigated without delay?
- 04What repairs and refurbishment have been completed in the bathrooms, clinic and laundry room?
- 05What extra guidance is now available for staff giving PRN medicines?
This was a focused inspection of Safe and Well-led, prompted by a specific incident; the other three key questions were not rated in this report. This explanation was written from the published report of 28 November 2020 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
6 rated inspections over 5 years: the service has improved, from Inadequate to Requires improvement.
- December 2021Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Lyndhurst Residential Care Home →
- November 2020Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
Read what inspectors found at Lyndhurst Residential Care Home →
- January 2019Goodup from Requires improvementSafe: GoodWell-led: Good
- December 2017Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2017Inadequatestayed InadequateSafe: Requires improvementEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- November 2016InadequateSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- January 2015
Report published without a new overall rating.
- November 2014
Report published without a new overall rating.
- May 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 14 December 2010.
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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