Lyngate Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance and record keeping at the service.

This service scored 57 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The home had recently changed ownership, though had retained the same provider name and details as part of this process. The new owners had drawn up a list of changes and improvements they wanted to implement, starting with a full renovation of the home. People and relatives had been informed of these plans, to ensure they felt included.

Within the home was a noticeboard on which the home’s values had been displayed. These consisted of taking ownership, achieving excellence, having commitment, communicating well and being caring. Details of how each of these would be achieved had also been included.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

A number of changes had occurred over the last 12 months, including a change in management, a new deputy being appointed and a change of ownership. This has understandably had an impact on the home and consistency in leadership. However, staff were happy with the current set up, telling us they felt the home was well run, the management team were approachable and had an open door policy.

Throughout the assessment process, the registered manager was open and honest. They acknowledged some areas required work but felt the support of the new owners would help in achieving this and ensuring people received the best care possible.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. However, guidance on how to do so was lacking in detail.

The provider had a whistle-blowing policy; however, this was very limited in detail, and essentially just stated people / staff had a legal right to blow the whistle, and any concerns should be reported to the registered manager. Should management be unable to satisfy the concerns raised, people / staff were entitled to take the matter to a legal representative, NCSC or government officer. The policy contained no contact details or phone numbers for people to use, nor explained what was meant by legal representative, NCSC or government officer. Some of the content of the policy was also inaccurate, and there was no reference to legislation which supports the whistle-blowing process.

Staff, people and relatives all told us they knew how to speak up and raise concerns and believed they would be listed to.

The provider did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider told us communication with staff was maintained via daily handovers and staff meetings. This provided an opportunity for staff to be involved in the home and be made aware of any changes. However, we identified issues with the documenting of staff meetings, which raised doubts about the validity of the minutes.

The home’s audit document stated, ‘has a general staff meeting, seniors meeting and housekeeping meeting been held in last 3 months.’ In light of this, we requested a copy of minutes for each of these meetings and was initially provided with 1 set of minutes dated July 2025, which had just been attended by care staff. We queried whether any additional meetings had been held and was later sent a separate document on which minutes had been collated for 3 meetings reportedly held on 5 November 2025, 1 December 2025 and 6 January 2026. We were also told, individual meetings were not held, just one big meeting for everyone.

However, within the latest audit document dated January 2026, it was documented all 3 meetings had been held on 28 November 2025. As the audit was completed at the end of January 2026, it was not clear why the meetings reportedly held on 1 December 2025 and 6 January 2026 had not been referenced. Nor was it explained if the staff meeting took place on November 5, as per the minutes document provided, why did the audit state the meeting had occurred on the 28 November 2025. As a result of these anomalies we could not be assured meetings had been held on the dates and times reported.

Staff views had been sought via a survey which was circulated in December 2025. Overall, scores and feedback received from those who completed it, were positive. Staff’s responses had been reviewed and summarised. The summary document also included some actions which would be completed to address issues raised through the survey process.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider did not have an audit schedule, which detailed what audits and monitoring were completed and how often. However, each month the registered manager had completed a ‘whole home audit’, which covered a range of areas including governance, environment, infection control, safeguarding, care files and medication.

We reviewed the last 6 months whole home audits. The ones completed in August and September 2025 were identical, for example they contained the same text, same findings and same actions, which suggested one was a copy of the other. The audit completed in October was largely the same as the previous 2 months, though there was some difference in the text and findings. However, we did not identity this issue on the remaining 3 audits.

We were not assured the audit process was robust. Within January 2026’s audit, training compliance was listed as being 97%. It was unclear how this figure had been worked out, considering some staff names had not been included on the matrix. The medicines section of the audit had not been completed, which meant by February 2026, medicines management would not have been audited for 2 months. Within the audit, it also stated all monitoring charts had been completed and to the agreed frequency, which did not reflect our findings from the assessment. Neither the January 2026 audit or ones completed prior to this, had identified any issues with staffing levels, staff supervision completion or that not everyone had been included on the training matrix.

We also found some actions identified through the whole home audit process had not been completed timely. For example, September 2025’s audit stated some risk assessments required updating and senior carers would complete this task within 1 week. However, this same issue has been identified and documented on each audit since. It was not clarified on the audits, whether these were the same risk assessments or different ones.

The provider’s Statement of Purpose (SOP) required review, as it incorrectly stated the types of service they provided. For example, it said the home provided nursing and residential care, despite it being a condition of registration that they did not provide nursing care themselves. It also stated they could support people living with dementia, physical disabilities and sensory impairments, despite not having these service user bands listed on their registration as required. The provider took steps to address this during the assessment.

People received regular involvement from health professionals. However, the provider was unable to evidence how they worked in partnership with other professionals and community groups. They did not always share information and learning.

The registered manager told us the home worked in partnership with a wide range of external organisations, including community groups, local businesses and health professionals. We saw evidence of the latter, with care records detailing professionals involvement in people’s care. However, nothing was shared with us to demonstrate how community groups or local businesses, had been involved.

We were also told community and voluntary groups supported social inclusion through visits, activities, and befriending though no evidence of this was provided either. We discussed with the provider, the importance of capturing involvement, discussing whether people enjoyed these visits and measuring the benefit for people.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The provider had an overarching service improvement plan (SIP) in place. This SIP contained 22 entries, with 12 of these listed as being complete. It was noticeable, all of the actions were linked to issues noted with people’s care records or care itself. For example, to review a specific care plan for an individual or ensure a specific risk assessment, such as for skin integrity, was completed for everyone. As such, it was unclear where other issues identified through the provider’s governance processes were documented, for example the actions which had been generated through the incident review process.

From reviewing the SIP, it was also apparent a number of deadlines had not been met. Each action included a date for completion. At the time of our assessment, of those actions still listed as in progress, all but one had missed the completion deadline. One, linked to the review of topical medicines risk assessments, should have been completed by June 2025. Others should have been completed by September, October and December 2025 and January 2026, but were still at various stages of completion, with limited information recorded on progress.