CQC report explained · a nursing home
What the CQC found at Lyndon Hall Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks, safeguarding, staffing, recruitment, infection control and medicines were generally managed safely. They identified isolated errors in medicine processes and two care-planning issues, which the home said it would correct immediately.
- Effective?
- Good
- People's needs were assessed, staff were trained and healthcare advice was followed. Inspectors noted that the environment, noise levels and support for one person sleeping through a meal needed more attention.
- Caring?
- Good
- People and relatives spoke positively about staff. Staff knew people well, respected choices and promoted independence, although inspectors saw some inconsistent attention to dignity on one unit.
- Responsive?
- Requires improvement
- Care plans were personalised and complaints were handled through a clear process. However, several people wanted more activities and outings, and some people said they were bored.
- Well-led?
- Good
- The home was described as well managed, with an approachable manager and consistent quality checks. Feedback from people and relatives was gathered and used to make changes.
What inspectors found, September 2019
Rated Good overall; inspectors found safe, effective and caring support, but activities and some aspects of the environment needed improvement.
This was an unannounced inspection on 23 July 2019. Inspectors spoke with 12 people living at the home, seven relatives and seven staff. They observed care and checked care plans, medicines, recruitment files, complaints, incidents and quality checks.
The home was rated Good for Safe, Effective, Caring and Well-led. Inspectors found enough staff, safe recruitment, suitable training, positive relationships and systems to monitor quality. People's care plans were detailed and their health, food and communication needs were generally met.
Responsive was rated Requires Improvement. Several people said they were bored and wanted more activities and outings. The home also needed to improve some dementia-friendly features, noise monitoring and consistency in small aspects of dignity and support.
The previous inspection, published in August 2018, rated the service Requires Improvement and found two breaches of regulation. Inspectors found that improvements had been made and that the provider was no longer in breach. The overall rating was Good, but the home was not rated Good in every area.
Safety and staffing
People told inspectors they felt safe and were not left waiting. Staffing levels were based on people's assessed needs, and recruitment checks were completed.
“People were kept safe as staff knew how to identify and report any concerns of abuse.” from the report
Trained staff
Staff had training, supervision and competency checks. Inspectors saw staff using equipment safely and supporting people effectively.
“People were supported by staff who had received appropriate training.” from the report
Kind relationships
Staff knew people well and supported their choices, routines, appearance and independence. People and relatives gave positive feedback about staff.
“People were supported by staff who knew them well and with whom they had positive relationships.” from the report
Personalised care
Care plans included people's needs, preferences, routines and cultural or religious wishes. People and relatives were involved in regular reviews.
“People's care plans provided good detail about people's needs as well as their preferences.” from the report
Active management
The home had regular audits and clinical oversight. The management team identified issues and used feedback and incidents to make improvements.
“There was a quality assurance system in place which had been used consistently to monitor and improve the quality of the service.” from the report
Too few activities
needs fixingSeveral people wanted more things to do and more outings. The activities worker had recently left, although the home had recruited for the post.
“Several people told us that they would like more things to do and to go out on visits.” from the report
Environment needs improvement
needs fixingThe décor and dementia-friendly design needed development. Noise was not being monitored, and several sounds at once could be overwhelming for some people.
“The décor of the premises needed improvement to meet people's specific needs.” from the report
Inconsistent dignity support
minorInspectors saw that some small details, such as providing tissues and plates, were not handled consistently on one unit.
“However, this was not consistent as we saw instances of where more attention to detail was needed.” from the report
Care detail
needs fixingOne diabetes care plan needed more information and one mattress setting was incorrect. The clinical lead said these issues would be addressed immediately.
“However, we found the diabetes plan for one person needed further information, and for another person requiring pressure relief, their mattress setting was incorrect.” from the report
- 01What activities and outings are now available, and how do you support people who are unable to join group activities?
- 02What changes have been made to the décor, signage, noise levels and dementia-friendly features since this inspection?
- 03How do you check that dignity standards, such as providing tissues and plates, are followed consistently on every unit?
- 04What checks are now in place to prevent errors with medicines, skin patches and tablet preparation?
- 05How are individual risks, such as diabetes care and pressure relief, checked and updated in care plans?
This was an unannounced planned inspection covering all five key questions, with the previous Requires Improvement ratings reassessed. This explanation was written from the published report of 4 September 2019 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 2018
Rated Requires Improvement; inspectors found concerns about staffing, medicines, care, activities and management.
This was an unannounced inspection on 7 June 2018. Inspectors spoke with people living at the home, relatives and staff. They observed care and reviewed care, medicines, staffing, training, incident and quality records.
The home was not consistently safe. Staff were not always available when people needed help, and medicines were not always stored, given or recorded safely. Food, support with eating and staff understanding of people's needs were also inconsistent.
Inspectors saw some kind and respectful care, but dignity was not always protected. Activities and care plans were limited in some areas. There was no registered manager, staff turnover was high, and the home's checks had not found several problems.
The home was rated Requires Improvement in all five areas and overall. This means the service was not consistently meeting the standards required, and the provider was told to take action.
Risk assessments
Risk assessments covered areas such as falls, moving and handling, skin care, diet and choking. Staff could explain people's risks and the equipment needed to support them.
“Risk assessments were in place for when people had been assessed for risks such as, skin checks, diet, food and choking risks and moving and handling and falls amongst others.” from the report
Safeguarding awareness
Staff knew how to recognise and report possible abuse or harm. They were also aware of whistleblowing and safeguarding procedures.
“Staff could tell us how they would recognise potential signs of abuse and how they would report these concerns.” from the report
Healthcare access
People could access healthcare professionals, including doctors, dentists and chiropodists. Staff described how they would respond if someone's health suddenly worsened.
“People had access to healthcare professionals such as GP's, dentists and chiropodists.” from the report
Choices and independence
People were given choices and encouraged to do what they could for themselves. Staff knew some people's preferences, including preferred forms of address and requests for female carers.
“We found that people were supported to be independent and that most people were encouraged to eat their meal in the dining room alongside others.” from the report
Improved communication
Communication between staff had improved since the previous inspection. Information boards helped many staff understand people's needs.
“At this inspection we found that communication between staff had been improved upon and that the use of the information boards were noted by a number of staff as being useful.” from the report
Staffing and availability
seriousPeople, relatives and staff reported that there were not enough staff. Inspectors found people waiting for help and being left without staff nearby.
“We found that staff were not always available to people when they required them.” from the report
Medicines safety
seriousSome medicines were not given at the prescribed times, stored securely or kept at the right temperature. Records and instructions for some medicines were incomplete.
“Administration and recording of medicines given was not always done safely.” from the report
Food and tube feeding information
needs fixingPeople had mixed views about the food, and support with eating was not consistent. Records about how much food one person could safely receive through a feeding tube were unclear.
“Some information shared that they could have five teaspoons of liquidised food, however others said 'small amounts'.” from the report
Dignity and respectful care
seriousInspectors saw people whose dignity was not protected and observed staff responding in an unkind or dismissive way. Some people were left without suitable support or interaction.
“We found that whilst some staff members maintained people's privacy and dignity, others did not.” from the report
Limited activities
needs fixingActivities had improved but were still limited. People who did not join group activities had little stimulation, and care plans contained limited information about hobbies and interests.
“However, for those who chose not to participate they experienced little stimulation.” from the report
Weak oversight
seriousThe home's audits did not identify several problems found by inspectors, including medicine storage, staffing, care records, activities and respectful care.
“This meant that there was no system or oversight to ensure staff were deployed effectively.” from the report
- 01What are the current staffing levels on each unit, including at night, and how do you check that people are not left waiting for help?
- 02What has changed in the storage, timing, recording and monitoring of medicines since this inspection?
- 03How are staff trained and checked on feeding risks, PEG support, the Mental Capacity Act and people's individual care needs?
- 04How do you protect people's dignity and make sure staff respond respectfully, especially when people need personal care or reassurance?
- 05What activities are now available for people who do not want to join group sessions?
This was an unannounced inspection that considered all five key questions and the overall quality of the home; it did not examine the circumstances of a person's death because that was subject to an external investigation. This explanation was written from the published report of 3 August 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 Lyndon Hall Nursing Home
4 rated inspections over 4 years: the service has held its Good rating throughout.
- September 2019Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- August 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- August 2017Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- April 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- October 2011
Registered with the Care Quality Commission on 31 October 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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