Lindisfarne CLS Residential

Updated 23 May 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Act.

Inspection team

An inspector carried out the inspection.

Service and service type

Lindisfarne CLS Residential is a ‘care home’. People in care homes receive accommodation and personal care as a single package under one contractual agreement dependent on their registration with us. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection the manager was not yet registered with the Care Quality Commission, but had made the relevant application.

Notice of inspection

The inspection was unannounced.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local commissioners and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 7 people who used the service and 2 relatives. We spoke with the manager, the deputy manager and 8 staff members. We also contacted all the staff and relatives via email.

We reviewed a range of records, which included 4 people’s care records, medicine records, staff files and a variety of records relating to the management of the service, including policies and procedures.

Updated 23 May 2023

About the service

Lindisfarne CLS Residential is a care home which provides nursing and residential care for up to 30 people. The service provides support to older people, people living with dementia and physical disabilities. At the time of our inspection, 26 people were living at this service.

People’s experience of using this service and what we found

People were satisfied with the service and felt staff always went above and beyond in delivering the care. They described the little extras staff just did as a part of their job. Staff were passionate about providing good care outcomes and took ownership for their practice.

Risk assessments were clear and readily identified how to reduce the risks to people. Staff were familiar with these documents and the actions they needed to take. We discussed how to enhance and develop some aspects of these documents, which the registered manager and deputy manager immediately acted upon.

The management team ensured there was always enough staff to support people. The nature of the service meant the number of people living at the home could rapidly fluctuate. On reviewing the staffing levels, it was decided to increase the number of staff, on duty so these variations could be managed more effectively. Recruitment practices met legal requirements and the registered manager used a variety of effective strategies to encourage people to apply to work at the service.

Medicines management was effective and closely monitored. Staff who administered medicines had the appropriate training. Staff adhered to infection control and prevention guidance.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. Staff had received training around the Mental Capacity Act 2005 and associated code of practice and felt confident applying this in their practice. Staff took steps to safeguard people and promote their human rights.

The systems the registered manager had in place allowed them to critically review the service and proactively looked at how improvements could be made. Staff told us the registered manager was approachable and listened to their views. All felt the registered manager was running a good service.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 16 February 2019).

In January 2021 we completed a focused inspection looking at infection control and prevention practice and were assured staff followed guidance appropriately.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

This report only covers our findings in relation to the key questions safe and well-led. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Lindisfarne CLS Residential on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.