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Inspection Summary

Overall summary & rating


Updated 14 February 2018

Lound Hall is registered to provide nursing and personal care to a maximum of 43 older people, some of whom were living with dementia. At the time of our visit there were 29 people using the service.

The inspection was unannounced and took place on 8 January 2018. We carried out this urgent focussed inspection following concerns about people’s safety and welfare from Suffolk County Council and the Clinical Commissioning Group (CCG).

On 31 October and 1 November 2017 we carried out an urgent comprehensive inspection in response to concerns about people’s safety and welfare. We were so concerned about what we found we took urgent action to stop the service admitting people. We also placed conditions on the registration of the service which requires them to send us regular information about the improvements being made. In January 2018 we received further concerns about a lack of improvement in the service and continuing risks to people’s safety and welfare. As a result we undertook an urgent focused inspection to look into those concerns. This report only covers our findings in relation to those topics. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Lound Hall on our website at

The service had 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.

People were put at the risk of significant harm in the absence of clear records and assessments which reflected all current areas of risk and how these should be managed to protect the person from harm. Basic care plans had been implemented for people; however, these did not provide adequate information for staff around meeting people’s specific complex needs.

Information received from the CCG demonstrated that there were continuing failures in the safe management of medicines.

Whilst some training had been carried out since our inspection, action was still needed to ensure that staff had the appropriate training and competencies to meet people’s complex needs safely.

There was a continuing failure of the management team to ensure that effective systems were in place to monitor the quality of the service. Limited progress had been made following our previous inspection and we were concerned that the management team had not identified risks to people and taken action to protect them. This was despite us providing clear information on the areas of risk following our inspection on 31 October and 1 November 2017 and the support provided by Suffolk County Council and CCG.

The service had assessed the dependency of people using the service and increased the staffing level. They did not have enough employed staff to cover all the shifts but had organised for agency staff to cover the deficit.

On the day of this inspection a new member of staff had started work at the service. They had been employed to be part of the management team and to facilitate and oversee improvements at the service.

Following our inspection we liaised with Suffolk County Council and the CCG to ensure that appropriate support was given to the service to keep people safe whilst improvements were made. We continue to work closely with other agencies to monitor the service and identify if there are further risks to people’s health, safety and welfare.

You can see what action we told the provider to take at the back of the full version of the report.

Inspection report

Inspection areas



Updated 14 February 2018

The service was not safe.

There remained significant shortfalls in risk management and systems in place to protect people from harm.

Care plans in place did not contain enough information to inform staff on how to meet people’s complex needs.

Information from the CCG demonstrated that medicines management at the service remained poor.

The service did not have enough employed care staff nor nursing staff to cover the required shifts. However, they were using agency staff to address this shortfall.

Inspection report



Updated 9 December 2017

The service was not effective.

People did not have their capacity to make decisions assessed and best interest’s decisions were not made appropriately.

The service was not taking appropriate action to monitor people’s risk of malnutrition and act on risk.

Improvements were required to the knowledge and training of staff.

Systems in place to support and drive improvement in the staff team had not been consistently implemented.


Requires improvement

Updated 9 December 2017

The service was not consistently caring.

Staff were kind and caring towards people.

Widespread significant shortfalls in the service meant that people’s health, safety and welfare was not upheld.

People and their representatives were not consistently involved in the planning of their care.



Updated 9 December 2017

The service was not responsive.

We observed that people were disengaged, bored and did not have access to appropriate stimulation and activity.

People's care records were not consistently person centred, and did not reflect in sufficient detail people's preferences or interests.

People had opportunities to feed back their views but told us they did not feel their views would be acted on.

The service did not learn from complaints.



Updated 14 February 2018

The service was not well-led.

The provider and management team had failed to make significant improvements in a timely way.

There remained significant shortfalls which put people at the risk of potential harm. Systems in place to monitor the quality of the service had been ineffective in identifying these shortfalls.

Inspection report