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Inspection Summary

Overall summary & rating


Updated 27 June 2018

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 ens

Inspection areas



Updated 27 June 2018

The service was safe.

Risks were managed well to help ensure people’s safety and well- being. A number of environmental risks had not been documented. The registered provider/manager assured us they would address this.

There were systems in place to help ensure people received their medicines safely and as intended. Staff were adequately trained and competent.

Staff knew how to safeguard people in their care and what actions to take if they felt a person was at risk. The service monitored risk and reported notifications to the local authority and CQC when necessary.

Staffing levels were adequate to people’s needs and staff worked well as a team.

The service was clean and there were good infection control procedures in place.

Staff recruitment was robust which helped ensure only staff suitable to work in care were employed.



Updated 27 June 2018

The service was effective

Staff were supported well and had adequate induction, training and support for their role. Staff had the necessary competencies to meet people’s individual needs. Staff kept up to date with legislation and best practice.

People were supported to eat and drink in sufficient quantities for their needs. Any unintentional weight loss was monitored and appropriate steps taken to reverse it.

Staff supported people to access health care as and when they needed to. People were supported to stay healthy and necessary steps taken when they became unwell.

Staff supported people in the way they wished to be supported with due regard for the Mental Capacity Act 2005 and the Deprivation of Liberties. Everyone was deemed as having capacity but staff were aware of how to support people in their best interest.

The accommodation was clean, well decorated and suited the needs of people using the service.



Updated 27 June 2018

The service was caring.

Staff were caring. They supported people to ensure their individual needs were met.

Staff encouraged people to be independence and to maintain friendships and links with family and community.

People’s privacy and dignity was upheld. Staff knew people’s needs and preferences and this was clearly documented and responded to.



Updated 27 June 2018

The service was responsive.

People’s needs were assessed before admission and kept under review. Care plans and risk assessments were completed and gave a good baseline for staff. They were person centred and reflected people’s preferences and wishes.

The service offered opportunities for people to engage in activity and to partake in community events and stay in touch with family and friends. We observed people joining in but felt there was insufficient activity going on.

The service supported people for as long as it was appropriate for then to do so. This included providing end of life care in line with people’s wishes.

The service took into account feedback from people using the service. This included both compliments and complaints. The service was responsive to both and showed actions they had taken when necessary.



Updated 27 June 2018

The service was well -led.

The service had a registered provider/ manager who motivated and supported staff. They ran a service, which took into account feedback and acted upon it. People were involved in decisions about their care and the wider service.

Audits helped to determine if the service was well led and if risks were mitigated. It also showed that people were receiving appropriate care.

Staff were motivated and demonstrated they had the necessary skills and values to enhance people’s experiences and provide individualised care.