During an assessment under our new approach
About the service
Lyons Court residential care home is a residential service providing personal care without nursing for up to 26 people. At the time of inspection 26 people were using the service. The service is based in the local community, set over 2 floors with access to gardens.
Who the service is for
The service supports older people and people living with dementia.
Key findings
We carried out this assessment from 29 September until the 7 October 2026. This service was previously rated as good. We carried out this assessment to confirm whether the rating of good remains accurate. This report does not provide detailed information on areas where we found practice continues to meet a good standard. Instead, our findings focus on any areas where the service needs to improve or where we found exceptional practice.
People consistently told us they were happy and felt safe living at the service. A person told us, “I am very happy here.” Another person said, “I like it here very much.”
People told us they were supported by staff who were kind and caring and were responsive to their needs. However, some people felt there were not enough staff and that staff often looked busy and rushed. Staff shared with us, although they had a good team they felt they needed an additional member of staff to meet the needs of people more effectively. The registered manager informed us they were in the process of recruiting additional staff to match the provider’s policy of over recruiting by a percentage to meet the demands of services. New staff underwent thorough recruitment checks and had a full induction to the service. We saw staff underwent regular training relevant to their role with some training being provided face to face. The registered manager told us they were undergoing training with another member of staff to have the skills to be able to deliver training on fire evacuation practices to staff.
People received their medicines as prescribed and where needed medicines were regularly reviewed by the GP practice. Staff told us they had their competency checked to support people with medicines safely. The registered manager completed audits of medicines to ensure their systems were working effectively.
People were safeguarded from the risk of abuse by staff who understood their responsibilities to report concerns. A member of staff told us, “I am up to date with my training. If I had a safeguarding concern, I would follow procedure and raise to the team leader or deputy manager. If it was not being dealt with I could ‘whistle blow’ or I could contact the local authority and CQC.” People consistently told us they felt safe living at the service. A person said, “I feel absolutely safe here.” Another person said, “Staff look after me here and keep me safe.” The registered manager raised safeguarding concerns appropriately and worked with the local authority to investigate these to keep people safe.
Care was person centred and assessments of people’s needs were completed before they started using the service. Care plans we reviewed contained good descriptions of how people wished to be supported, their preferences, and were individually tailored to meet each person’s needs. Risks were assessed and mitigated to keep people safe. However, we found some documentation could be improved with additional details of acute needs when these arose. We discussed this with the registered manager who informed us the provider had been working with staff to review care plans and ensure all details were added and up to date.
People and relatives told us they had an opportunity to visit the service before they made any decision about living there. A relative told us, “The registered manager came to our home and did an assessment. We were given the opportunity to view the home.” They went on to say that initially the placement was for respite, but they were happy with the service and so it became permanent.
Staff had systems to monitor people’s health needs. The registered manager told us they worked closely with the GP surgery who held weekly meetings with them to review people’s health. Where indicated the GP referred people to other health professionals such as dietitians and speech and language therapists. There were also regular visits from the district nursing team to review people and address individual health needs such as wound care. People received regular treatment for their foot health and other appointments were made as necessary with opticians and dentists. The provider also had qualified health care staff working for them who could give staff advice and support them with making onward referrals to the GP service. The registered manager told us the provider’s health care staff visited the service at least monthly or more when requested to help with reviews of people. In addition, the provider had their own out of hours on call where staff could ring for clinical advice. The registered manager informed us this service gave staff the support they needed to access healthcare promptly for people. A visiting health professional told us, “I do home visits for acute illnesses. I find the staff are all very knowledgeable about people’s needs and how they are presenting. The staff are very on the ball and responsive.”
People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found staff and management worked within the MCA. DoLS authorisations were appropriately applied for and overseen. People were not subject to unlawful or excessive restrictions. They had choice, control and freedom over their lives. Where conditions of DoLS were in place the registered manager ensured these conditions were met. The registered manager worked closely with people’s advocates to ensure their rights were being upheld and their voices heard. Staff had received training in the capacity act and understood their role in ensuring people had choice over their care and support.
Staff had regular meetings to discuss people’s care needs and the running of the service. A member of staff told us, “The daily meetings are really helpful, we have a handover and discuss residents.” Staff had regular supervision sessions where they could discuss any issues they had. Staff told us they did not always feel listened to or that their issues were addressed. We discussed this with the registered manager about how supervision sessions could evidence issues are discussed, and a resolution reached or support evidenced to enable staff to feel listened to.
The environment was clean and well maintained. The registered manager employed a maintenance person for the day-to-day maintenance at the service. They were supported by the provider’s maintenance team when needed. We saw safety certificates were held and up to date, a recent fire risk assessment had been completed. The service was clean and fresh, people told us their rooms were cleaned daily, and they had their personal possessions which made it feel homely.
The registered manager promoted equality in experience and outcome for people. The registered manager had systems in place to measure and monitor outcomes for people, including gaining feedback during resident and relative meetings and from surveys. The provider had just completed the 2026 survey with 21 responses being analysed. Relatives and people told us communication was good with the service, and they felt confident to raise any concerns.
The registered manager had systems to keep oversight of the service. There were audits and a service improvement plan which was updated with the outcomes and actions from audits. The registered manager held regular meetings with their heads of department and completed clinical review meetings of people’s care to ensure people were receiving the support they needed in a timely way. The provider maintained oversight of the service with provider audits and regular monitoring from their regional directors.