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Lynfords Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 19 July 2019

About the service:

Lynfords is a residential care home for up to six people and there were six people using the service at the time of our inspection. People living at Lynfords needed support with personal care, mobility, health, behavioural and communication needs. Accommodation was on ground floor only and the building had been specifically designed to meet the needs of people with physical disabilities.

For more details, please see the full report which is on the CQC website at

People’s experience of using this service:

Guidelines in one person’s care plan were not followed during inspection and some care plans did not included advice to meet people’s identified health needs. The provider’s governance systems had not identified shortfalls found at this inspection. For example, that a follow up to a fire drill that had not gone well had not been carried out. There had been limited monitoring to ensure people received activities as planned. The staff skill mix on the morning of our inspection was not appropriate to ensure people’s needs were met.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

The outcomes for people using the service reflected the principles and values of Registering the Right Support. People were supported to make choices in all areas of daily living from choosing clothes to wear to what they wanted to do. There were regular opportunities to use local facilities and amenities and people had equipment that enabled them gain new skills to increase their independence in whatever way they could.

There were enough staff who had been appropriately recruited, to meet people’s needs. Staff understood what they needed to do to protect people from the risk of abuse. Incidents and accidents were well managed. People’s medicines were managed safely.

Staff attended regular training to update their knowledge and skills. They attended regular supervision meetings and told us they were very well supported by the management of the home.

People were supported to attend health appointments, such as the GP or dentist and attended appointments for specialist advice and support when needed. People had enough to eat and drink and menus were varied and well balanced.

A visiting professional told us, “Staff are always pleasant, and the residents have always been cared for appropriately.”

Staff were kind and caring. They had a good understanding of people as individuals, their needs and interests. Most people needed some support with communication and were not able to tell us their experiences; those who could told us they were happy, and we observed that people were happy and relaxed with staff.

People were supported to take part in activities to meet their individual needs and wishes. This included trips to the local parks, theatres, cafes and restaurants, trips to places of interest and college. Entertainers provided musical entertainment and we observed one of these. This activity was lively and inclusive, and people were observed to really enjoy the activity.

The environment was well maintained. The bathroom and shower room had recently been refurbished. The provider had ensured safety checks had been carried out and all equipment had been serviced. Fire safety checks on equipment were all up to date.

Rating at last inspection: At the last inspection the service was rated good. (The last inspection was published 4/11/2016).

Why we inspected: This was a planned inspection based on the rating at the last inspection.


We found two breaches of Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what actions we asked the provider to take at the back of the report.

Follow up:

We will continue to monitor intelligence we receive about the service

Inspection areas



Updated 19 July 2019

The service was safe.

Details are in our Safe findings below.



Updated 19 July 2019

The service was not always effective.

Details are in our Effective findings below.



Updated 19 July 2019

The service was caring.

Details are in our Caring findings below.


Requires improvement

Updated 19 July 2019

The service was not always responsive.

Details are in our Responsive findings below.


Requires improvement

Updated 19 July 2019

The service was not always well-led.

Details are in our Well-Led findings below.