CQC report explained · a residential care home
What the CQC found at Lisieux House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People told inspectors they felt safe. Staff understood risks, safeguarding and people's needs, and there were enough staff. Additional information was needed in some as-required medicine protocols, and ventilation in one shower room needed improvement.
- Effective?
- Good
- Care plans reflected people's needs, wishes and goals. Staff had relevant training and people had access to healthcare, specialist advice and support with eating and drinking.
- Caring?
- Good
- Staff treated people with kindness, dignity and respect. People and relatives were involved in decisions, and staff supported independence and family relationships.
- Responsive?
- Good
- People helped decide how they spent their time, what they ate and which activities they took part in. Staff supported communication, community activities, personal goals and contact with families.
- Well-led?
- Good
- The manager promoted a positive, person-centred culture. Audits, feedback and review systems were in place, and issues identified during the inspection were acted on promptly.
What inspectors found, March 2022
Rated Good; inspectors found kind, personalised care, with some minor improvements still needed.
This was an unannounced inspection on 21 and 22 February 2022. One inspector visited the home, spoke with nine people, six staff and three relatives, and reviewed care records and management documents.
The inspectors found that people were safe, supported by enough staff and given their medicines safely. Care was personalised and staff understood people's needs, communication and preferences. People were supported to make choices, build independence, maintain relationships and take part in community activities.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. This means inspectors found a good standard of care and management, although it does not mean that everything was perfect.
The home did not fully meet current guidance about small, ordinary homes forming part of the local community. The provider had plans to address this. Some medicine protocols, records and ventilation arrangements also needed minor improvement, with actions taken or planned during the inspection.
Staff knew people well
Staff understood people's individual needs, wishes, goals and early signs of distress. This helped them provide personalised support and manage risks.
“Staff had a very good knowledge of the people they supported and were able to tell us about people's individual needs, wishes and goals.” from the report
Kind and respectful care
Inspectors saw staff support people at their own pace and with kindness. Relatives were strongly positive about the care and support given.
“Staff engaged with people in a respectful and kind manner. Staff sat and spoke with people and supported people at a pace that suited them.” from the report
Choice and independence
People were involved in everyday decisions and were encouraged to develop skills, pursue interests and take positive risks safely.
“People were involved in all aspects of the day to day running of the home including choice of meals, how they spent their time at home, activities they wanted to do and places of interest they wanted to visit.” from the report
Community and family links
People took part in activities outside the home, including meals out, walks, local events and community projects. Staff also helped people maintain family relationships during the pandemic.
“People told us about a range of things they enjoyed doing and were encouraged to engage in a meaningful way in the local community.” from the report
Supportive leadership
The manager was visible and approachable, and staff said they felt supported. Management used audits and feedback to monitor and improve the service.
“Regular checks and audits were carried out by the management team and provider in order to oversee the quality of the service.” from the report
Home design and community setting
needs fixingThe home did not fully meet current guidance about small, ordinary homes forming part of the local community. The provider had plans and was discussing them with people and families.
“Lisieux House does not fully meet the current guidance on small, ordinary homes forming part of a local community.” from the report
As-required medicine instructions
needs fixingSome protocols for medicines taken when needed did not contain enough information. The manager added the information during the inspection.
“Protocols for medication taken on an 'as required basis' needed some additional information added and this was actioned by the registered manager during the inspection.” from the report
Shower-room ventilation
minorThe provider's own checks had identified that ventilation in one shower room needed improvement to help prevent mould. Plans were in place to address this.
“The providers own audits had identified that ventilation in one shower room needed improvement to prevent the build-up of mould.” from the report
Minor record improvements
minorSome records needed minor improvements. These were dealt with during the inspection.
“Some records required some minor improvements, and these were actioned during the inspection.” from the report
- 01What changes are planned to make the home better meet current guidance about small, ordinary homes in the local community?
- 02What additional information was added to the as-required medicine protocols, and how is this checked now?
- 03Has the ventilation in the shower room been improved, and has the risk of mould been resolved?
- 04How are people and families being involved in decisions about the home's future buildings and accessibility?
- 05How do you check that care records remain accurate and up to date as people's needs change?
This was the first inspection of the newly registered service and covered all five key questions, including infection prevention and control and the principles of right support, right care and right culture. This explanation was written from the published report of 31 March 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Lisieux House
4 rated inspections over 7 years: the service has held its Good rating throughout.
- March 2022Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2016Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2020
Registered with the Care Quality Commission on 15 May 2020.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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