CQC report explained · a residential care home
What the CQC found at Lyle House
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, December 2022
Rated Requires Improvement; inspectors found kind, respectful care but concerns about staffing, safeguarding knowledge and management.
This was an unannounced focused inspection on 21 November 2022. Two inspectors and an executive team member visited the home, spoke with people, staff and relatives, and reviewed care, medicines, risk and management records.
People were generally treated kindly and with respect. Inspectors found effective infection control, suitable risk plans, well-managed incidents and accidents, and medicines records that were clear. However, staffing shortfalls were not always covered quickly, and there were not always enough staff identified to evacuate people safely in a fire.
The home was rated Good for Caring, but Requires Improvement for Safe and Well-led. The overall rating fell from Good at the previous inspection, published on 6 August 2021. Inspectors made recommendations about staffing and safeguarding knowledge.
Kind and respectful care
People and relatives described staff as kind, polite, friendly and respectful. Inspectors found that privacy, dignity and independence were supported.
“People were well supported, with their individual needs met.” from the report
Risk and incident management
Care records gave staff guidance about risks such as falls, malnutrition, skin problems and distress. Accidents and incidents were investigated, with learning shared with staff.
“Incidents and accidents were investigated to ensure that lessons were learned.” from the report
Infection control
Inspectors were assured that infection prevention measures, cleaning, hygiene and protective equipment were being used effectively.
“We were assured that the provider was using PPE effectively and safely.” from the report
People's choices and needs
The home worked within the Mental Capacity Act principles. Care plans included people's histories, preferences, cultural and religious needs, and ways to support independence.
“People were supported to be as independent as they were able to.” from the report
Staffing and fire evacuation
seriousStaffing shortfalls were not always covered quickly. Records showed there would not always have been enough staff to evacuate people in line with their personal emergency evacuation plans during a fire.
“Records showed that there would not have been enough staff to evacuate people in line with their personal emergency evacuation plans (PEEPSs), in the event of the fire.” from the report
Safeguarding knowledge
needs fixingSome staff were not clear about which outside agencies they could contact to escalate safeguarding concerns. Inspectors recommended regular refreshers in safeguarding knowledge.
“Staff were not always clear on where concerns could be raised outside of their organisation.” from the report
Communication with relatives
minorSome relatives said they did not receive as much communication as they wanted about their loved ones. The manager said communication methods would be improved.
“Communications with relatives were not always as frequent as they could be.” from the report
Inconsistent leadership
needs fixingThe home had a history of inconsistent leadership. The new manager was making improvements, but inspectors still found areas needing improvement.
“The home had a history of inconsistent leadership.” from the report
- 01How are staffing shortfalls covered now, including at weekends and during sickness?
- 02How will you ensure there are enough staff to evacuate every person according to their personal emergency evacuation plan?
- 03How are staff being refreshed on where to report and escalate safeguarding concerns outside the home?
- 04What changes have been made to keep relatives updated about their loved one's care?
- 05What progress has the new manager made against the action plans referred to in the report?
This was a focused inspection of Safe, Caring and Well-led; Effective and Responsive were not inspected, and the previous ratings were used when calculating the overall rating. This explanation was written from the published report of 20 December 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.
What inspectors found, August 2021
Rated Good; inspectors found safe, personalised care and strong management, with some records needing closer checking.
This was an unannounced focused inspection on 1 and 7 July 2021. Inspectors spoke with people living in the home, relatives, managers and staff. They also checked care records, recruitment files, complaints, medicines and management records.
The home was rated Good overall. Safe, Responsive and Well-led were each rated Good. Inspectors found enough staff, safe recruitment, safe medicines practice, suitable infection control and good risk management. People and relatives said they felt safe and well cared for.
Care plans were detailed and activities were based on people's interests and life histories. The home listened to complaints and used audits and feedback to improve. However, inspectors found that refusals of personal care were not always recorded, so the provider introduced extra checks and refresher training during the inspection.
This was a focused inspection because of safeguarding concerns raised through anonymous whistleblowing. Effective and Caring were not inspected at this visit. Their ratings from the previous comprehensive inspection were used when calculating the overall rating.
Safe staffing
Inspectors found safe recruitment and enough staff to meet people's needs. Call bell response times were regularly checked.
“The majority of calls were answered in under 2 minutes which was in line with the providers expectations.” from the report
Safe medicines
Medicines were stored securely and managed by trained staff. Records and stock checks were accurate.
“Medicines were managed consistently and safely in line with national guidance.” from the report
Personalised activities
Activities reflected people's interests and life histories. The home was developing more life-history information to support this approach.
“People were supported to take part in activities that they enjoyed and personal life histories were considered when planning activities.” from the report
Quality monitoring
Managers used audits, surveys and provider visits to find areas for improvement and check that actions were completed.
“These were effective in identifying areas of improvement which were then subsequently actioned.” from the report
Incomplete personal care records
needs fixingWhen people refused personal care, this was not always recorded. The provider responded during the inspection by introducing checks and arranging refresher training.
“where they had refused, this is not always documented.” from the report
- 01How do you now check that refusals of personal care are recorded fully and promptly?
- 02What refresher training on documentation have staff completed, and how do you check that it has improved records?
- 03How do you use people's life histories, likes and dislikes when planning their activities?
- 04How are call bell response times monitored, and what happens if responses take longer than expected?
- 05How are complaints and safeguarding concerns reviewed and used to make improvements?
This was a focused inspection of Safe, Responsive and Well-led; Effective and Caring were not inspected and their previous ratings carried over into the overall rating. This explanation was written from the published report of 6 August 2021 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 Lyle House
6 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- December 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2021Goodstayed GoodSafe: GoodWell-led: Good
- July 2018Goodup from Requires improvementSafe: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- January 2017Requires improvementstayed Requires improvementSafe: GoodEffective: Requires improvementResponsive: Good
- June 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2015
Registered with the Care Quality Commission on 13 February 2015.
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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