Archived: Lyles House

Updated 4 March 2021

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

As part of CQC’s response to the coronavirus pandemic we are looking at the preparedness of care homes in relation to infection prevention and control. This was a targeted inspection looking at the infection control and prevention measures the provider has in place.

This inspection took place on 27 January 2021 and was announced on 26 January 2021.

Updated 4 March 2021

Lyles House provides accommodation and personal care for up to eighteen people. This comprehensive inspection took place on 3 May 2018 and was unannounced. There were eighteen people living in the home when we inspected.

The last inspection at this service was on1 March 2017. In 2017 the service was rated requires improvement in the key question of safe and well led with a breach of regulation 12 Safe care and treatment. This means that the service was rated ‘Requires Improvement’ overall. At that inspection, we assessed the care as being safe but identified risks associated with the environment, which could have affected people’s safety. The registered provider/manager took immediate actions and submitted an action plan to tell us what they had done.

At this inspection on the 3 May 2018, we found the service offered safe care and have rated it good against all key questions we inspect against. There were certain aspects of the service which were very good but other areas of the service which could be strengthened to enhance people’s experiences

Lyles House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a registered manager who was also the registered provider. 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.

At this inspection, on the 3 May 2018 we found Lyles House was a well- planned, well- managed service. People said they felt safe and in the main risks were well documented in relation to people’s individual’s needs. Adequate steps were taken to mitigate risk as far as reasonably possible. The service had a low number of incidents, accidents and falls. We attributed this to the steps the service had taken reduce risk. However, we identified a couple of potential risks, which had not been adequately responded to. This was fed-back to the registered provider/manager to address.

People received their medicines as intended by staff who were sufficiently trained and competent. Medicines were audited to ensure they were available and administered as required. Medicines were only prescribed when necessary and reviewed to ensure they remained appropriate to the needs of the individual.

Staffing levels were sufficient and staff worked cohesively to ensure people’s needs were met in a timely manner. The hours specifically allocated to activities were limited and if increased would further enhance people’s well -being.

Staff understood how to keep people safe and who to report concerns to if they suspected a person was at risk or harm or actual abuse. Staff were confident in their role and felt able to report issues internally and externally if necessary.

The service recorded accidents, incidents or any event affecting the well- being and safety of people using the service. The service was open and transparent and lessons were learnt.

The registered provider/manager had adequate staff recruitment processes to help ensure only suitable staff were employed. Once employed staff were supported to work independently and as part of the team. Staff received support, supervision and training to help them fulfil their role. Staff kept up to date with best practice through training updates and a detailed induction to care.

People were supported to stay adequately hydrated and receive sufficient nutrition. This was monitored to help ensure people did not have unintentional weight loss and if this happened, steps were taken to reverse it. People had their health care needs met. Their needs were carefully monitored and steps taken to ensure people had access to other health care professionals.

Staff had a good understanding of the Mental Capacity Act 2005 and sought to provide care according to people’s express wishes and after gaining their consent.

People’s needs were assessed before moving into the service. Care plans and risk assessments gave staff a good insight into people’s needs and how they wished to be supported. These were regularly reviewed and families were involved and consulted. Staff knew people well and provided high standards of individualised care.

People were supported with their end of life care and staff ensured people’s wishes and dignity was upheld.

People chose their routines and staff respected this. Different activities were provided in the afternoon including external activities. People lived in pleasant surrounding and could choose to socialise or sit quietly, although the way the chairs were arranged did not encourage people to socialise. They also had access to gardens, which were nicely maintained.

There was an established complaints procedure, which took into account feedback from people and showed how this had been addressed. We saw lots of positive feedback and an overarching quality assurance system.

The service enhanced peoples well -being by providing personalised care. People had established good relationships with other people and the staff supporting them. Staff were kind and respectful and clearly enjoyed working at the service. There were different opportunities for people to join in activities and to maintain contact with family, friends and the wider community. However, this was limited.

The service was well managed and run in the interest of people using it.

Staff were supported and sufficiently competent. The registered provider/manager was open, transparent and working hard to provide a service which was the best it could be.

Regular audits and feedback from people shaped the service and helped the home improve and develop.