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Lumley Residential Home Requires improvement

The provider of this service changed - see old profile


Inspection carried out on 25 November 2020

During an inspection looking at part of the service

Lumley Residential Home is a residential home providing personal care to older people, people living with a dementia and people with learning disabilities. It accommodates up to 40 people in one purpose-built building. There were 25 people using the service when we visited.

We found the following examples of good practice.

• Systems were in place to allow safe visiting, including screening visitors before they could enter the building.

• Social distancing was encouraged and communal areas had been adapted to promote this.

• Staff wore personal protective equipment (PPE) to keep themselves and people safe.

• The registered manager and provider proactively supported people and staff wellbeing through the challenges of coronavirus.

• Regular coronavirus testing was taking place.

Further information is in the detailed findings below.

Inspection carried out on 11 February 2020

During a routine inspection

About the service

Lumley Residential Care Home provides personal care to 26 older people, who are living with dementia. There is a separate seven bed facility for adults with learning disabilities called Jeffrey Court. On the day of inspection there were 23 people living on Lumley Court and six people living on Jeffery Court.

Jeffrey Court had been developed and designed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. This ensures that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence. People using the service did not always receive planned and co-ordinated person-centred support that is appropriate and inclusive for them.

The provider had recognised that further work to support people with a learning disability was needed and had started to implement improvement plans.

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

Medicines were not managed safely, and we observed staff on both Lumley Court and Jeffrey Court, not following best practice.

People felt safe and supported by staff who knew them well. Risk assessments were in place. Staffing levels were appropriate to people’s needs. Incidents and accidents were documented and analysed to help identify any developing patterns. Staff worked in conjunction with a range of external healthcare professionals.

Staff said they felt supported. However, supervisions were more about discussing policies or overall staff concerns such as mobile phone use, rather than the staff members wellbeing. The registered manager said they had recognised this and changed the way they hold supervisions as from January 2020. Staff were not fully up to date with their training.

We have made a recommendation about ensuring supervisions were more supportive and training was up to date.

The dining experience needed improving. Food and fluid charts did not evidence that people were receiving enough food and fluids throughout the day.

People's needs were assessed and reviewed. People did not always receive person centred care on Jeffrey Court, we found there was a lack of choice, control and independence.

We have made a recommendation about following best practice guidelines for people with a learning disability.

We received a mixed response about the activity provision. People’s rooms were pleasantly decorated to their tastes.

The provider had quality assurance and auditing processes in place. However, these had failed to recognise all the concerns we found.

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 27 September 2017).

Why we inspected

This was a planned inspection based on the previous rating.


We have identified breaches in relation to the safe management of medicines and records at this inspection.

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

Follow up

We will request an action plan from 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 carried out on 14 August 2017

During a routine inspection

The inspection took place on 14 August 2017. The inspection was unannounced and was carried out by an adult social care inspector and an expert by experience.

We last inspected the service in June 2015 and rated the service as Good overall with Requiring Improvement in the Responsive domain. At this inspection we found the service remained good and met all the fundamental standards we inspected against.

There was a registered manager in post. A registered manager is a person who has registered with the 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 and associated Regulations about how the service is run.

Within Lumley Residential Home there is a separate unit called Jeffery Court which caters for a group of younger adults who may have a learning and/ or physical disability. We spent time in all areas of the service during this inspection.

There were safeguarding procedures in place. Staff were knowledgeable about what action they should take if abuse was suspected. The local authority safeguarding team informed us that were no current safeguarding concerns regarding the service.

The premises were clean. Checks and tests had been carried out to ensure that the premises were safe.

There were safe systems in place to receive, administer and dispose of medicines.

We found that recruitment checks were carried out to ensure that staff were suitable to work with vulnerable people.

Staffing levels were provided to meet the needs of people using the service. Records confirmed that training was available to ensure staff were suitably skilled. Staff were supported through an appraisal and supervision system.

The MCA provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that as far as possible people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. The application procedures for this in care homes and hospitals are called the Deprivation of Liberty Safeguards (DoLS). We saw the service identified where an authorisation may be required and followed the correct procedures to apply and maintain a DoLS.

People's nutritional needs were met and they were supported to access healthcare services when required.

We observed positive interactions between staff and people who lived at the service. Staff promoted people's privacy and dignity. There were systems in place to ensure people were involved in their care and support. The service ensured people had access to independent advocacy support services.

Care plans were in place which detailed the care and support to be provided for people. These had been improved to reflect a more person centred approach and showed more involvement from people who used the service.

There was an activities coordinator employed to help meet the social needs of people. The service was working with an external activity company and also had hens in the garden that people helped look after. People were supported to access the local community.

There was a complaints procedure in place. Feedback systems were in place to obtain people’s views.

The provider had a quality assurance process in place that checked on the quality of the service and ensured that people were consulted about the running of the home.

The provider was meeting the conditions of their registration. They were submitting notifications in line with legal requirements. They were displaying their previous CQC performance ratings at the service and on their website.

Inspection carried out on 11 and 12 June 2015

During a routine inspection

This inspection took place on 11 and 12 June 2015 and was unannounced. This meant the provider did not know we planned to carry out the inspection.

We carried out our last inspection of Lumley Court in September 2013 when we found the provider was compliant with the required regulations.

Lumley Court is part of the Willington Care Village, a group of homes owned by Bondcare Willington Limited. Lumley Court is registered to provide care for up to 26 older people with dementia care needs who require assistance with their personal care. The home does not provide nursing care. A section of the building is known as Jeffrey Court which provides accommodation for up to eight people with learning disabilities.

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.

The provider had a robust recruitment and selection procedure in place and carried out all relevant checks when they employed staff.

We looked at people’s personal emergency evacuations plans (PEEPS) and observed the plans in place to support people evacuate the building correlated with people’s needs as described in their care plans.

The provider had in place a number of building checks; we saw these included the testing of fire alarms, water testing and portable electrical testing (PAT). We also saw the provider had in place tests for water temperatures and nurse call bells.

The provider was meeting the requirements of the Deprivation of Liberty Safeguards (DoLS) and had made applications to the appropriate authority to deprive people of their liberty, where it was in their best interests.

Training records were not up to date. Staff however received regular supervisions and appraisals to support them in their role.

Everyone we spoke with told us they liked the food in Lumley Court.

Staff treated people with dignity and respect. This was confirmed by people using the service.

We saw people’s rooms were personalised with their possessions; this meant people were able to have their familiar things around them.

Staff were able to tell us about individual people, their needs, likes and dislikes.

We found the service was not proactive in having personalised activity plans in place which responded to people’s individual preferences or prevented social isolation.

We found the provider had in place transfer records documented a summary of the person’s stay and their condition when they left the home. This meant the provider was able to account for the service the person received whilst in their care.

The manager demonstrated they had plans in place to improve the environment and people’s lifestyles.

The provider had changed their auditing arrangements to reflect the CQC inspection questions of is the service safe, effective, caring, responsive and well-led and had put in place actions to improve the service.

We found the provider offered care to people in conjunction with other community based support services.

During our inspection we found the provider was in breach of a regulation. You can see what action we told the provider to take at the back of the full version of the report.

Inspection carried out on 20 September 2013

During a routine inspection

We spoke with seven people out of twenty nine who use the service and three visitors on the day of the inspection. Not everyone we spoke to could express their views, but those that could, told us they were very satisfied with the service they received. People felt that the staff supported them and met their needs. One person said, �They do a grand job here; the staff are so kind and helpful�.

We saw staff speaking and responding to people in a happy, gentle and respectful manner. We found records to show how people's health needs had been assessed before they came to live in the home. Full assessments were then completed once the person was in residence. Assessments included information from health and social care professionals to make sure the home could provide the care people needed.

We saw that people were listened to and supported to remain as independent as possible. People and visitors told us that if they had any complaints they would not hesitate to speak to the manager or staff. One visitor said �Staff are very approachable and will do anything to help�.

Staff told us that they felt supported within the service and had opportunities to develop their skills with additional training opportunities. One staff member said �We are encouraged to do training�.

We found that systems were in place to monitor the service that people received, including suitability of the premises. This meant that the service was satisfactory and safe.

Inspection carried out on 29 August 2012

During a routine inspection

We spoke with two people living at the service. We also observed the way staff

assisted and spoke with the people living there, during lunchtime and at other times

throughout the day. The comments we heard included "It's lovely; cannot grumble" and "The staff are very kind hearted".

We also observed the way staff assisted and spoke with the people living there. One person said, "There's good carers and there's caring carers. These are caring carers".