Lyngate Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to staffing. Specifically, ensuring enough staff were deployed to meet people’s needs and that staff had received enough training and supervision to carry out their roles safely and effectively.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Although staff listened to concerns about safety, they did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

We looked at how the provider documented accidents and incidents, and any learning linked to these. The registered manager agreed to send us a copy of their accident and incident log, which should contain this information. However, this document was missing from the initial batch of information sent to us for review offsite. After re-requesting it, a document was provided. However, this was a replica of the safeguarding log we had previously been sent, with a change made to the title, so it now read ‘safeguarding log / incidents and accidents’. The log contained limited information about the nature of any accidents and incidents, what actions had been taken, any outcomes and lessons learned.

We also requested a copy of the provider’s complaint log. The document provided contained a summary of the 4 complaints received, the findings of the investigation into each of these, the outcome and some information on lessons learned, and changes to practice. Whilst this information was detailed, it was apparent this was not a contemporaneous record, as the complaints were not documented in chronological order.

In December 2025, the registered manager introduced a new process to review incidents and accidents. At the time of the assessment, this had been done once, with the review covering a 9 week period up to the 4 February 2025. We were told the plan was for this to be done each week moving forwards. The review looked at what incidents had occurred, tried to identity key themes, along with make recommendations and actions to prevent a reoccurrence. A separate coaching plan had also been completed. This was staff‑specific and identified key themes, training needs, and any actions required for specific staff, based on the findings of the incident review.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The provider worked closely with social workers, health professionals and families to support the transition process whether into or out of the home. Assessments were completed and shared across services, as was people’s care records as and when necessary to ensure continuity of care

The provider shared concerns quickly and appropriately and worked well with people and healthcare partners to understand what being safe meant to them and how to achieve that. However, the process for investigating and documenting safeguarding concerns required strengthening. It was not always clear what actions had been taken and if improvements had been made.

People told us they felt safe living at the home. Staff had received training in safeguarding, though some staff’s training was due for renewal.

Safeguarding concerns had been reported in line with local authority guidance. The provider documented any safeguarding issues on a log. However, the log lacked detail. For example, when explaining what had happened, actions taken and outcomes, only a few words had been used. For example, ‘incontinent pad issue / delayed response, reviewed and continence care reinforced’ or ‘concerns of neglect and deterioration, closed after transfer to a nursing home.’ From what was recorded, we could not determine whether a full and detailed investigation had taken place, nor whether any actions taken had been successful. It was also not clear whether any learning had occurred or changes to practice made to reduce the likelihood of a reoccurrence.

Deprivation of Liberty Safeguards (DoLS) are an important part of the Mental Capacity Act 2005. They involve providers seeking legal authorisation from the local authority where they need to deprive people lacking capacity of their liberty. For example, preventing them from leaving the care home without support, or having keypads on internal doors which prevents free movement. DoLS aim to ensure that such deprivations of liberty only happen when it is necessary, proportionate and in the person’s best interests. DoLS applications had been submitted as and when required, with a log used to monitor applications and their outcome.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Where possible, people had been involved in discussions about keeping them safe and managing risks. Care records contained detailed guidance about how staff should minimise risks to people, ensure equipment was used safely and people’s environment was considered to ensure it was safe. For example, for a person who had reduced mobility and at risk of falls, guidance included ensuring their walking frame was to hand, they wore well fitting, non-slip footwear, their room was free from clutter, rugs and any trailing wires or trip hazards and that adequate lighting was maintained.

Where people used specific equipment such as a hoist to help transfer them. Detailed step by step guidance was in place for staff. This guidance was clear and easy to follow and ensured any procedures were completed safely.

Risk assessments were reviewed periodically to ensure they remained effective and met people’s changing needs.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Risk assessments of the environment and equipment used within the home had been completed, to ensure these were fit for purpose and used correctly. Ongoing safety checks had also been completed in line with legislation, with certification in place to confirm compliance. This included checks of gas and electrical safety and equipment such as the passenger lift and hoists. An up to date fire risk assessment was in place.

Following the change in ownership, the home was undergoing a full refurbishment. This had obviously resulted in some disruption, though people told us they were okay with this, and looked forward to seeing the outcome. At the time of our site visits, final touches to a new lounge were being completed, new flooring was being installed in specific areas and decorating work had commenced.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.

People and relatives provided mixed views on staffing levels. Comments included, “I don't think there is probably enough staff around” and “The staff are very good, though I think they are stretched and when anyone is off sick, they struggle.” Observations made during the assessment supported this. Staff were attentive and did their best to respond to needs timely. However, due to how busy they were, care was largely task orientated.

The provider used a system, known as a dependency tool, for determining how many staff were needed to meet people’s needs. The tool assesses how much support, measured in minutes, each person requires throughout the day, these are then added up to give an overall total for the home in hours. This is then cross referenced to the number of staffing hours available. The aim is for staffing hours to equal or exceed the number of care hours required. However, the home’s tool showed 175 care hours were required each day to meet people’s needs, yet staffing hours only equaled 120, a shortfall of 55 hours per day.

The incident review document completed by the registered manager had identified a need to review dusk to dawn supervision levels, due to a number of unwitnessed falls which had occurred between December 2025 and February 2026. This indicated staffing levels may not be sufficient to ensure effective oversight.

Staff training completion was documented on a matrix. From the information provided, we were unable to confirm all staff were up to date with training the provider considered mandatory and was needed to ensure people’s needs could be met. Some of the data was also confusing, for example, 1 staff member only commenced their induction in August 2025, yet was listed as having completed 7 training courses in March 2025. Another staff was listed as having completed 16 training courses in 1 day.

The provider used a colour coded system to indicate if training was in date. However, as the matrix did not indicate the frequency with which each session needed to be completed, we could not be fully assured completed sessions remained in date.

Staff supervision meetings were documented on a matrix. The providers policy stated these should occur every second month, or 6 times per year. This frequency had not been achieved, with the matrix indicating staff had only attended either 1 or 2 meetings in the last 12 months. The matrix for 2024 showed a similar pattern.

A number of staff competency assessments had been completed, to observe staff practice whilst carrying out care. Areas covered included privacy dignity, wellbeing and manual handling.

Staff were recruited safely, with all required pre-employment checks completed and references sought.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

We found the home to be clean, with robust infection prevention and control (IPC) processes in place. We observed housekeeping staff throughout the home, with checklists and records in place to evidence good cleaning practices. Guidance was on display regarding hand hygiene, use of personal protective equipment and the management of outbreaks.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. This was predominantly due to record keeping issues.

The provider had not maintained a contemporaneous record of the use of thickening powder, used to thicken the drinks of people with swallowing difficulties or at risk of aspiration. Thickening powder had been signed for on the home’s electronic medicines record system (eMAR), however, only 4 times per day, and people had consumed drinks more frequently than this. Fluid intake was logged on the provider’s electronic care planning system, however, staff had not consistently recorded these drinks had been thickened, so we could not be assured they had been made to the correct consistency. However, as no choking incidents linked to fluid intake had occurred in the last 6 months, this was likely a record keeping issue.

Medicines competencies had been completed to assess staff’s skills and knowledge. When completed in February 2026, 2 staff were deemed to require improvement. However, there was no further details on what the issues where, nor what action had been taken to provide assurance these staff were competent and safe to administer medicines.

Staff had documented the temperature of the medicines fridge consistently each day. However, they were only recording the maximum temperature, rather than the minimum, maximum and actual temperatures as per best practice. The registered manager agreed to address this straight away.

The registered manager was in the process of introducing new documentation to support safe medicines processes. These included detailed prompt sheets and person centred information sheets, which provided information on people, their health needs, allergies, safety wishes and what help and support they needed. Where people had specific types of medicine, such as tablets which needed to be taken before meals or not with any other medication, clear guidance was in place, which detailed what the medicine was for, how to take, how to actually administer it e.g. place in person’s hand, and what to do if they didn’t take it as planned.

Where people needed to be given their medicines covertly (without their knowledge) the provider had sought authorisation to do so from the GP and a pharmacist. Guidance was also in place which explained how each medication should be administered. For example, ‘Can crush and give with small amount of liquid or food. Staff must crush 1 tablet at a time, using named tablet crusher, mix with soft, cool food or 15 – 30ml of liquid, and give in first mouthful’.

Records indicated people had been given their medication each day and at the right time, in line with their prescription