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Archived: Lancaster Inadequate

Inspection Summary

Overall summary & rating


Updated 13 January 2017

We carried out an unannounced focused inspection of this service on 09 and 14 December 2015. This was because we received information of concern about the service. The concerns related to missed and late visits, administration of medication and delivery of the care provided.

After the inspection in December 2015, we received further concerns about missed and late visits. We also received information of concern regarding the disposal of important records. As a result, we undertook a further focused inspection on 03, 09 and 15 March 2016.

We undertook this focused inspection to assess if people were safe. The visit on the 03 and 09 March was unannounced. The provider was notified prior to our visit on the 15 March 2016. This report covers our findings in relation to this inspection only. You can read the report from our last inspection by selecting the 'all reports' link for Lancaster on our website at

At this inspection we judged the provider continued to be in breach of Regulation 12 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Safe Care and Treatment and Regulation 17 Health and Social Care Act 2008 (Regulated Activities) Good Governance. The service was also in breach of Regulation 9 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Person Centred Care and Regulation 18 Care Quality Commission (Registration) Regulations 2009 Notification of other incidents.

Lancaster is registered to provide personal care to people living in their own homes. At the time of our inspection, 31 people were receiving a personal care service. The office is based at Riverway House, which is situated between Lancaster and Morecambe. The service provides care and support for older persons, dementia care, end of life care, long-term conditions, respite care and night care.

There is a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.

During this inspection, we looked at electronic systems and documentation that showed not all people who required support receive their scheduled visits. This left them at risk, because the provider did not provide the care and treatment identified to meet people’s needs.

Records we looked at showed people who required a service did not always receive their allocated support time. We saw that the length of time carers were due to stay with people as part of a scheduled visit had been shortened to allow staff to complete additional visits elsewhere.

We saw examples of where people who were scheduled four visits a day, had received three visits because two of the visits had been merged. This placed vulnerable people at risk. They did not receive safe and effective support with their physical and mental health requirements.

Risks were identified with the electronic monitoring system. The system was not effective as it did not always show when visits had not occurred. When the system did show missed visits, the staff member operating the system was unable to explain why they had occurred.

People were not given the support they needed with medicines as directed within the care plans.

Ongoing medical conditions were not managed safely.

Care plans identified risks, although information was brief and lacked detail to guide staff on how to manage the risk. This placed people at risk of harm.

There were safeguarding policies and procedures in place. We saw the provider had raised a safeguarding concern with the local authority in relation to theft. They had not notified the Care Quality Commission as required.

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

Inspection areas



Updated 13 January 2017

The service was not safe.

Risks to people's safety and wellbeing were identified. However, documentation did not contain information to minimise and manage risk factors. This placed people at risk of harm.

Identified medical conditions were not managed in a safe manner and placed people at risk of harm.

The provider shortened or moved scheduled visits without consultation with people who received support.

Missed visits were not always identified or dealt with. This placed vulnerable people at risk.



Updated 27 January 2016

The service was effective.

Staff had the appropriate training and support to meet people’s care needs.

Staff had the appropriate knowledge and skills to meet the needs of people using the service.

There were policies in place in relation to the Mental Capacity Act 2005. Care files showed people or their representatives had consented to receiving support in their own homes.

People were supported to make choices about the food they wished to eat and drink as identified in their care plan. Staff received food hygiene and infection control training.


Requires improvement

Updated 27 January 2016

The service was not consistently caring.

Feedback from people was positive and they were happy with the care and support they received. However some of the people we spoke with told us they had requested but not received a list of staff who would be visiting, which was important and mattered to them.

People and their relatives were involved in planning their care and

support. People felt that staff listened and responded appropriately.


Requires improvement

Updated 27 January 2016

The service was not always responsive.

People's individual needs had been assessed and recorded in their support plans. We looked at care plans which showed these support needs and preferences had not been reviewed and updated regularly.

People said that staff were sometimes late and they were not informed. Some people told us their rota did not always reflect who arrived to support them.

Staff felt their concerns and complaints were listened to and responded to accordingly. Complaints and any action taken were not always recorded.



Updated 23 March 2016

The service was not well-led.

Systems in place for reviewing the quality of the service were not effective.

The registered manager had consulted with people they supported for input on how the service could continually improve. They had not acted on feedback received.

The call monitoring system was not effective. It was inaccurate and did not always show when visits had not occurred.

The registered manager had clear lines of responsibility and accountability in place.