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Archived: Lammas Lodge

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All reports

Inspection report

Date of Inspection: 21 June 2011
Date of Publication: 8 August 2011
Inspection Report published 8 August 2011 PDF

The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care (outcome 16)

Not met this standard

We checked that people who use this service

  • Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety.

How this check was done

Our judgement

People had been put at risk and have experienced poor outcomes due to ineffective monitoring of the service.

User experience

People using the service were not protected by the company’s quality monitoring systems.

Other evidence

The manager told us a senior manager visits the home each month to monitor the quality of the service and provide him with supervision. They then write a report about their findings that is shared with other senior staff in the company. We saw the report from the visit in May 2011. This indicated that the home was running well and the manager had completed the in-house monthly audits that form part of the quality monitoring process.

The manager’s alleged failure to submit numerous incident reports to the company may have made it more difficult for senior staff to identify the problems at the home. However, staff and other professionals closely involved in the home were aware that serious incidents were occurring frequently so their views cannot have been effectively sought or followed up. Other shortfalls such as poor record management systems, staff shortages on the rota and gaps in care plans should have been denitrified.