CQC report explained · a residential care home
What the CQC found at Lydia Eva Court
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found risks were assessed and managed, there were enough staff, recruitment checks were completed and medicines were generally managed safely. They noted some gaps and omissions in medicines records.
- Effective?
- Good
- Staff had relevant training, supervision and competency checks. People received enough food and drink, had access to healthcare and were supported to make choices under the Mental Capacity Act.
- Caring?
- Good
- Staff were described and observed as kind, respectful and compassionate. People’s privacy, dignity, independence, choices and family relationships were promoted.
- Responsive?
- Good
- Care was personalised and plans were reviewed and updated. People could choose activities and routines, and complaints were listened to and responded to.
- Well-led?
- Good
- The home had effective quality checks, open communication and a positive culture. Inspectors said the provider was no longer in breach of Regulation 17 from the previous inspection.
What inspectors found, March 2018
Lydia Eva Court was rated Good; inspectors found significant improvement, with caring staff and safe care, although some medicines records needed attention.
Inspectors visited on 17 and 30 January 2018. The first visit was unannounced. They observed care, spoke with people living in the home, relatives, visitors and staff, and checked care plans, medicine arrangements, recruitment records and quality checks.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicine management, good training, kind and respectful care, personalised support and effective management systems.
The home had previously been rated Requires Improvement in four areas, with an overall rating of Requires Improvement in December 2016. Inspectors said significant improvements had been made and that appropriate action had been taken.
Improvement since the last inspection
The home had acted on the previous inspection findings. Inspectors found significant improvements across the service and rated all five areas Good.
“The findings from our inspection on 17 and 30 January 2018 confirmed that appropriate action had been taken and significant improvements had been made.” from the report
Kind and respectful care
Staff knew people well and supported their dignity, privacy, choices and independence. Inspectors observed warm and reassuring interactions.
“Staff were caring and kind and promoted people's privacy and dignity.” from the report
Personalised support
People were involved in their care planning and supported to follow their interests. Activities included exercise, crafts, cooking, singing and community visits.
“We saw that the care provided was centred around each person as an individual and staff tried to find ways to help ensure that people could be included and involved in meaningful activities and entertainment.” from the report
Strong management checks
The management team and provider carried out regular audits and used incidents, complaints and feedback to make improvements.
“We saw that the service now had effective quality assurance systems in place and regular audits were carried out to monitor and improve the quality of care.” from the report
Some medicine storage records had gaps
minorMedicine storage temperatures were checked, but some daily records were missing entries.
“The temperatures at which medicines were stored were monitored and recorded, however, we noted some gaps in the daily records.” from the report
- 01How do you make sure written instructions are available for every medicine given when needed or at a variable dose?
- 02How do you record that medicated skin patches have been removed before new patches are applied?
- 03What changes were made to the security arrangements for controlled drugs after the inspection?
- 04How do you monitor medicine storage temperatures and follow up missing daily records?
- 05How do you respond when staff are busy or relatives feel staff may be stretched?
This inspection looked at the overall quality and safety of the home, including accommodation and care, and reviewed all five CQC questions. This explanation was written from the published report of 22 March 2018 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.
What inspectors found, December 2016
Rated Requires Improvement; inspectors found kind care and safe medicines practice, but important risks and records were not managed consistently.
This was an unannounced inspection on 1 and 2 November 2016. Inspectors spoke with people living in the home, relatives, visitors, staff and a social care professional. They observed care and checked care records, medicines records, recruitment files, training records and quality checks.
The home was caring, and people generally said staff were kind, respectful and responsive. Inspectors also found enough staff, suitable recruitment checks, good medicines management, appropriate safeguarding processes and an environment designed to support people living with dementia.
However, some people's risks were not properly recorded, reviewed or managed. There were also unclear nutritional instructions, incomplete and inaccurate care plans, and quality checks that had failed to find or correct these problems. The overall rating was Requires Improvement. The home breached Regulation 17 on good governance.
Kind and respectful staff
People and relatives spoke highly of staff's kindness, patience and compassion. Inspectors observed staff reassuring people who were distressed or confused.
“People spoke highly of the caring, thoughtful and compassionate approach of the staff and that it made them feel reassured and cared for.” from the report
Dignity and independence
Staff supported people to make choices, protected their privacy and encouraged them to do as much as possible for themselves.
“Staff maintained people's dignity and encouraged their independence.” from the report
Medicines management
Medicines were stored securely and records checked by inspectors were accurate and complete. Staff administering medicines had training and regular competency checks.
“The MAR charts we viewed were accurate and legible. They had been fully completed and included relevant explanations wherever medicines had not been administered.” from the report
Supportive environment
The home had dementia-friendly signs, themed areas, memory boxes and enclosed outdoor spaces to support orientation and engagement.
“The décor was clean, bright and themed for interest.” from the report
Approachable management
People, relatives and staff said the management team was visible, friendly and willing to listen. Feedback was collected through meetings and surveys.
“The people who used the service, their relatives and staff spoke highly of the registered manager and deputy manager.” from the report
Unclear special-diet guidance
seriousCare records gave conflicting information about diets and thickened fluids. The cook did not have all the information needed about individual dietary requirements and staff had not received diabetes awareness training.
“These discrepancies put the person at risk as staff did not have clear and accurate guidance on what nutritional support this person required to keep them safe and well.” from the report
Inaccurate care plans
needs fixingSeven of the 13 care plans checked contained discrepancies or incomplete information. Documents were stored in different places, making it harder for staff to find a full and current picture of a person's needs.
“Out of the 13 care plans we viewed in depth during our inspection, seven contained discrepancies or incomplete information.” from the report
Quality checks missed problems
seriousAudits covered too few care plans and did not identify important risks or documentation errors. The provider had already identified some audit problems, but they had not all been corrected.
“The provider had failed to have effective systems in place to assess, monitor and improve the quality and safety of the service.” from the report
Limited organised activities
minorStaff regularly interacted warmly with people, but inspectors saw few organised activities during most of their time in the units. Some relatives thought there should be more activities.
“However, for most of our time spent in the various units of the home during our inspection, we did not see many activities taking place.” from the report
- 01What changes have you made to ensure falls, injuries and choking risks are recorded, reviewed and acted on promptly?
- 02How do you make sure every staff member has the correct, up-to-date instructions for each person's diet, fluids, allergies and food preferences?
- 03Are all care records now accurate, person centred and stored where staff can quickly find them?
- 04How do you check that care plans match the care people receive, and how do you follow up problems found by audits?
- 05What organised activities are available for people with different interests, including people living with dementia?
This was an unannounced inspection covering all five CQC questions, with observations, discussions and checks of 13 care records and five people's medicines records. This explanation was written from the published report of 30 December 2016 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 Lydia Eva Court
2 rated inspections over a year: the service has improved, from Requires improvement to Good.
- March 2018Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- June 2014
Registered with the Care Quality Commission on 12 June 2014.
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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Most charge £990 to £1,120 a week. 9 can care for a couple. 14 years' experience on average.
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