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Inspection Summary


Overall summary & rating

Good

Updated 28 April 2018

This inspection took place on the 7 and 8 March 2018 and was unannounced.

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

Lyme House accommodates up to 21 people with a diagnosis of an acquired brain injury (ABI). The home is part of the transitional rehabilitation unit group (TRU). There were 13 people living at the home at the time of our inspection. The home is situated in the Haydock area.

The service had a registered manager. 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 of the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At the last inspection on 25 and 28 April 2017 we found that there were a number of improvements needed in relation to safe care and treatment and good governance. These were breaches of Regulation 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Following the last inspection, we asked the registered provider to complete an action plan to demonstrate what they would do and by when to improve the key questions Safe and Well-led to at least good. The provider sent us an action plan which specified how they would meet the requirements of the identified breaches. During this inspection we found that all required improvements had been made.

This inspection was carried out to check the improvements that had been made by the registered provider to meet the legal requirements after the comprehensive inspection undertaken April 2017. The team of two inspectors inspected the service against all the five questions Safe, Effective, Caring, Responsive and Well-led. We found that the registered provider was meeting all of the legal requirements.

Improvements had been made to the management of medicines and the completion of required documentation. Medicines were ordered, stored, administered in accordance with good practice guidelines by competent staff that had received appropriate training.

Improvements had been made to the governance systems undertaken by the registered provider at the home. Regular audits were undertaken, analysis was completed and areas for development and improvement were identified and actioned.

Safe recruitment procedures were evidenced and sufficient numbers of staff were available to meet the assessed needs of the people living at the home. A comprehensive induction had been completed by all staff. Staff had received training appropriate to their role which was regularly updated. Staff were supported in their roles and attended regular team meetings and shift handovers.

Staff had all received up-to-date safeguarding training and understood their responsibility to raise any concerns about the people they supported. The registered provider had clear safeguarding policies and procedures in place.

People’s needs were assessed before they moved into the home and this information was used to create detailed risk assessments and individual person centred care plans. People’s independence was promoted throughout all documentation. All documents were reviewed regularly and amended when there were any changes to people’s needs.

People’s needs that related to age, disability, religion or other protected characteristics were considered throughout the assessment and care planning process.

People had access to activities of their choice, college placements and vocational opportunities. The management team had developed positive relationships with local community organisations.

Staff had developed positive relationships with the people they supported. People told us their right to privacy and dignity was respected

Inspection areas

Safe

Good

Updated 28 April 2018

The service was Safe.

People's medicines were ordered, stored and administered in line with good practice guidance by staff that had received training and were competent.

Recruitment procedures were robust. Sufficient staff were recruited to meet the individual needs of the people living at the home.

Risk assessments gave clear guidance to mitigate risk and promoted people's right to choice and independence.

Effective

Good

Updated 28 April 2018

The service remains Good.

Caring

Good

Updated 28 April 2018

The service remains Good.

Responsive

Good

Updated 28 April 2018

The service remains Good.

Well-led

Good

Updated 28 April 2018

The service was Well-led.

The clinical governance process regularly reviewed the effectiveness of audits undertaken.

The registered provider sought feedback through a variety of means including meetings and questionnaires.

The registered provider had a range of up to date policies and procedures available that offered guidance to staff.