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Archived: Lancaster Lodge Inadequate

Richmond Psychosocial Foundation International is no longer providing care services at Lancaster Lodge. We will update this page to reflect this change of status soon.

Inspection Summary

Overall summary & rating


Updated 24 June 2016

Our last inspection of the service took place on 1, 2, 3 and 8 March 2016 and was unannounced. During that inspection we found seven breaches of regulations as a result of which we rated the service as inadequate. These were in relation to person centred care, safe care and treatment of people, safeguarding adults from the risk of abuse, dealing with complaints, good governance, staffing and sending notifications about significant events to CQC as all providers are required to do. We are taking actions against the provider for the above breaches of regulations and will report on these when our actions are complete.

This unannounced inspection took place on 10 and 11 May 2016 in response to a serious incident that happened at the home and to check if people using the service were safe. The report should be read in conjunction with the report we produced after our unannounced inspection of March 2016.

Lancaster Lodge is a care home for up to 11 adults with mental health needs.

The home did not have a registered manager. The previous manager left on 18 January 2016. 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 and associated Regulations about how the service is run.

The provider did not have effective systems to manage risks and where risks were identified, comprehensive plans were not in place to ensure risks were managed appropriately and in a consistent manner.

The provider did not have proper arrangements to ensure people received their medicines as prescribed so they received the treatment prescribed by their doctor.

Some risks in relation to the safety of the premises, more specifically about the storage of cleaning products and other chemicals, were not managed appropriately to fully ensure the safety of people who use the service.

There were conflicting records meaning people were not protected from known risks. These included records associated with nutrition and hydration as staff were given conflicting directions to follow in relation to keeping people using the service safe.

The provider did not ensure appropriate skilled and experienced staff were deployed at the home to meet the various needs of people who used the service.

We found two continued breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We are taking action against the provider in combination with the findings of our inspection in March 2016 in accordance with our enforcement policy. We shall report on this when our action is completed.

Two people said that currently they felt safe living at the home and had now got used to the new staff and felt better supported by them.

Staff said they had received appropriate support with their work including support to come to terms with a serious incident which occurred at the service.

The overall rating for this service continues to be ‘Inadequate’ and the service is still in ‘Special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent e

Inspection areas



Updated 24 June 2016

Whilst people said that they felt safe, we found that the provider did not have effective arrangements to ensure risks were assessed, monitored and mitigated. This meant there were risks to people�s safety, health and welfare.

The house was not kept clean, cleaning materials were not suitably stored and there was out of date food and unlabelled food in the fridge, which could pose a risk to people using the service

Medicines were not managed safely.



Updated 8 June 2016

The service was not effective.

Not all staff had been adequately trained or supported to meet people�s needs. People�s needs were not effectively met and agreed with them. Not everyone had a support plan. The support plans that were in place were not up to date, meaning people�s food and fluid intake was not monitored, although staff encouraged people to have balanced and nutritious diets.

There were no mental capacity assessments, outcomes decisions or Deprivation of Liberty Safeguards (DoLS) in place. New staff had not received training in the Mental Capacity Act 2005. This meant people�s rights were not protected.


Requires improvement

Updated 8 June 2016

The service was not always caring.

People felt that staff tried hard to meet their needs on a daily basis. They did not feel valued or respected by the management, organisation and were not involved in planning and decision making about their care. People�s preferences for the way in which they were supported were not suitably met or clearly recorded.

Care was centred on people�s immediate individual needs, in a re-active and unplanned way. New staff and the management were not familiar with people�s background, interests, personal preferences well and needs. Staff provided support, care and encouragement as best they could in a chaotic environment.


Requires improvement

Updated 8 June 2016

The service was not always responsive.

Peoples' recreational and educational activities were greatly reduced by the lack of organisation, support and record keeping. Two peoples' support plans were missing and the information for thee others was out of date. Activities only continued due to the knowledge of the few experienced staff still in post. The daily notes did not contain information that would inform staff coming on duty of what to expect. Regular care reviews were not taking place or being recorded.

People and relatives told us that any concerns raised were either not discussed and addressed or not done so as a matter of urgency.



Updated 8 June 2016

The service was not well-led.

The home had a negative culture that was not focussed on people or their individual needs. People were not familiar with the management structure or who was responsible for running aspects of the service. The management and its structure did not enable people to make decisions by encouraging an inclusive atmosphere.

Staff were poorly supported and the training provided did not equip them to meet people�s needs.

There were no discernible quality assurance, feedback and recording systems in place for the service to monitor standards or drive improvement.