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Lyndhurst Residential Care Home Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 28 November 2020


Lyndhurst is a residential care home providing personal care to 13 people aged 65 and over at the time of the inspection, including people living with dementia. The service can support up to 20 people. The service is a domestic style property and accommodation is over three floors

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

Although assurance and auditing processes were in place, they were not always effective and did not always mitigate risk to the health and welfare of people living at the service.

The service did not always identify and report accidents and incidents appropriately. Incidents were not analysed effectively meaning that people were exposed to a risk of harm.

Environmental and health and safety checks had not identified that some fire doors did not operate effectively, meaning there was a risk to people.

The appearance of the physical environment was tired in places and in need of refurbishment, including bathrooms. However, it was recognised that the service was in the process of an improvement plan.

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.

Safe recruitment practices were in place for staff and there were enough staff to meet people’s care and support needs.

People and their relatives spoke positively about the staff and care received by their loved one. One person told us, "It feels like home, the staff are lovely and know me well. I have everything I need."

For more details, please see the full report which is on the CQC website at

Rating at last inspection

The last rating for this service was Good (published January 2019).

Why we inspected

The inspection was prompted by notification of a specific incident. Following which a person using the service sustained a serious injury. This incident is subject to an external investigation. As a result, this inspection did not examine the circumstances of the incident.

The information CQC received about the incident indicated concerns about the management of falls from height and missing persons. This inspection examined those risks.

We have found evidence that the provider needs to make improvements. Please see the Safe and Well-led sections of this full report. The overall rating for the service has changed from Good to Requires Improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Lyndhurst on our website at

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Inspection areas


Requires improvement

Updated 28 November 2020

The service was not always safe.

Details are in our safe findings below.



Updated 28 November 2020



Updated 28 November 2020



Updated 28 November 2020


Requires improvement

Updated 28 November 2020

The service was not always well-led.

Details are in our well-led findings below.