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Archived: Lyndhurst Residential Home Inadequate

Inspection Summary

Overall summary & rating


Updated 20 February 2020

About the service

Lyndhurst Residential Home is a residential care home providing personal care to 14 people aged 65 and over at the time of the inspection. The service can support up to 15 people.

The home is a converted property with two communal lounges and a dining room. Bedrooms are situated in the ground and first floor.

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

People were not always protected from the risk of harm. Although people told us they felt safe, risks to people’s health and safety were not always identified or robustly assessed. Some areas of the environment posed a risk to peoples safety. People were not adequately protected from the risk of fire, the kitchen was not clean, and medicines were not always stored safely. There were enough staff on duty and recruitment procedures were safe.

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. However, care records did not include assessments of people’s capacity to make decisions regarding specific aspects of their care. People were enabled to access other health care professionals. There was effective communication between staff. Staff had received training and supervision. Feedback about the meals was positive but records relating to people’s food and fluid intake needed to be improved.

Staff were caring and kind. People’s right to privacy was respected and staff took steps to maintain people’s dignity. Confidential information was stored securely.

Information in people’s care files was detailed and person centred, although we noted one person who had been living at the home for two weeks did not have a care plan in place. People were not enabled to engage in meaningful, person centred activities. There was a system in place to manage complaints in the event people were dissatisfied.

The service was not well led. There was a lack of robust and effective leadership. Systems of governance were weak and ineffective. Quality monitoring systems had not highlighted where there were concerns or issues, had consistently failed to ensure regulatory compliance and had not identified the issues we have raised as part of this inspection. There was no evidence the registered provider monitored the quality of the service people received. Despite our findings, people told us they were happy with the care provided and staff felt supported by the registered manager.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 26 April 2019) and there were three breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made and the provider was still in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.


We have identified breaches in relation to person centred care, consent, safe care and treatment and governance.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the 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.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Inspection areas



Updated 20 February 2020

The service was not safe.

Details are in our safe findings below.


Requires improvement

Updated 20 February 2020

The service was not always effective.

Details are in our effective findings below.


Requires improvement

Updated 20 February 2020

The service was caring.

Details are in our caring findings below.


Requires improvement

Updated 20 February 2020

The service was not always responsive.

Details are in our responsive findings below.



Updated 20 February 2020

The service was not well-led.

Details are in our well-Led findings below.