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Inspection Summary

Overall summary & rating


Updated 2 April 2016

We carried out an unannounced comprehensive inspection of this service on 18 August 2015 and a breach of legal requirements was found. After the comprehensive inspection the registered provider wrote to us to say what they would do to meet legal requirements in relation to the breaches. We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Lindsey Lodge Hospice on our website at

We undertook this inspection on 18 February 2016. The inspection was announced. When we had previously inspected this service on 18 August 2015 it was rated requires improvement overall, with a requires improvement rating in two domains; 'safe and well-led.' We had issued a requirement notice for shortfalls found in the medicine management at the service, which was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. During this inspection we found that the registered manager had made improvements to the auditing and medicine management within the service which ensured that the shortfalls we had previously found had been addressed.

Lindsey Lodge is a purpose built hospice that provides inpatient care and treatment for a maximum of 10 people who have a life limiting condition. The service can also provide day care support for up to 14 people each day. Accommodation is provided on the ground floor with all rooms having good access to gardens and patio areas. En-suite and communal bathrooms with shower and assisted bathing facilities are provided, some with overhead hoist facilities to help meet people's mobility needs. There are two shared occupancy rooms which can be opened up to create a four bedded unit. This area can be changed to make two large bedrooms where family can stay close to their relative. There is a separate out-patient suite with craft rooms, communal areas and therapy rooms. Separate family accommodation has been recently built which is available for use; these facilities include are en-suites with televisions and tea making equipment. During our inspection there were people being cared for on

the in-patient unit and the out-patient clinic was open for people to use. Car parking facilities are provided with disabled parking by all entrances.There are local amenities, shops, a pub and garage nearby.

The service has a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The hospice director is the registered manager of this service.

We found improvements had been made in regard to the ordering of medicines, storage and monitoring of the temperature of the medicine storage room and fridge. Stock levels of medicines were monitored by staff and the management team. The medicine policy and procedure had been reviewed and had been rewritten to ensure it provided robust guidance for all staff in all areas of medicine management. We did not speak with people using the service directly about their medicines because the issues relating to medicine management that we had found at our last inspection on 18 August 2015 did not directly affect patient care or their symptom control.

We found that the registered provider and registered manager had been proactive and developed improvements to the quality monitoring systems within the service which were effective at highlighting any issues. Action plans were put in place which helped to monitor, maintain or improve the service which was provided to people.

Inspection areas



Updated 2 April 2016

The service was safe.

We saw improvements had been made, and we have changed the rating from requires improvement to good for this key question.

Improvements had been made to the medicine management systems within the service relating to the ordering, recording and storage of medicines.

Robust policies and procedures for medicine management were in place and effective auditing had been introduced by an external pharmacist.



Updated 14 October 2015

The service was effective. Staff and volunteers undertook a programme of training to help them to deliver effective care and support to people with life limiting conditions.

People’s mental capacity was assessed. Correct action was taken to ensure people were not deprived of their liberty unlawfully. This helped to protect their rights.

People’s hydration and nutritional needs were assessed and were monitored. Special requests for different foods were catered for to encourage people to eat. Food provided looked nutritious and appetising.

People were supported by relevant health care professionals and complimentary therapists.



Updated 14 October 2015

The service was caring. People told us they were well cared for. We observed that the staff and volunteers supported people with kindness and compassion.

Staff supported people’s family and friends during their illness and after the person had died. People’s religious needs were known and were provided. The service had a ‘contemplation room’ for quiet reflection and prayer.

People and their relations were treated with dignity and respect.



Updated 14 October 2015

The service was responsive. People’s views and experiences were taken into account in the way the service was provided and delivered in relation to their care.

People had their needs assessed on admission and their care records were continually updated as their needs changed. This ensured people received the care and support they required.

The service provided complimentary therapies and specialist clinics to help people with symptom control, such as pain and swollen limbs. Services were available to provide psychological support to people and their family.

Multi-disciplinary team meetings were held to discuss people’s conditions and needs. This allowed a variety of therapists and specialist health care professionals to give their views on the support and treatments available.

Effective complaints procedures were in place. Issues raised were investigated and resolved.



Updated 2 April 2016

The service was well led.

The ethos of the service was positive; there was an open and transparent culture and a friendly, welcoming environment. Staff understood the management structure of the service, their roles and responsibilities.

The quality monitoring of the service had been improved and included a range of audits as well as detailed medicine management auditing which was completed internally and by an external pharmacist.

A robust controlled drugs policy, for staff to refer to was in place.

Improvements were being made to the times when people could be admitted to the service.

People were asked for their views about the service and feedback received was acted upon.