CQC report explained · a care home with nursing
What the CQC found at Lyons Court Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, June 2023
Requires Improvement; inspectors found unsafe cleanliness and weak oversight, although medicines, safeguarding and staff attitudes were positive.
The unannounced inspection took place on 18, 25 and 31 May 2023. Inspectors reviewed care and medicines records, management records and the premises. They spoke with people, relatives, staff and outside professionals.
The home was not always clean or well maintained. Some communal areas, dining furniture and shower chairs were dirty. Infection control arrangements were not always followed. Governance checks had not found problems or ensured that known issues were fixed.
Medicines were managed safely, people were protected from abuse and risks were assessed. People, relatives and staff spoke positively about the manager, staff culture and care. The overall rating changed from Good at the previous inspection to Requires Improvement.
Medicines
People received their medicines when needed. Records of administration were clear and medicines were stored securely.
“Medicines were managed safely. People received their medicines when needed, and clear records of administration were kept.” from the report
Safeguarding and risk
Staff knew how to raise safeguarding concerns. People's risks were assessed and reviewed, and people were supported in line with the Mental Capacity Act.
“Risks to people were assessed and action was taken to address them.” from the report
Approachable leadership
People, relatives and staff described the manager and management team as approachable. Feedback was sought and acted on.
“A relative told us, "The overall view I have is that they are approachable, and the office door is always open, and people are available if you need to speak to them.” from the report
Positive staff culture
Staff were described as friendly, helpful and focused on people's best interests. People and relatives spoke positively about care outcomes.
“Staff gave us positive feedback on the culture and values of the service.” from the report
Cleanliness
seriousSome communal areas, dining furniture and shower chairs were dirty. The report says the premises were not always suitable for use.
“The premises were not always clean. We saw that some communal areas, including dining rooms and bathrooms, were dirty and had not been effectively cleaned.” from the report
Infection control
seriousClinical waste was not always disposed of correctly and protective equipment was not stored in a way that prevented contamination. Some treatment-room areas were also dirty.
“Infection prevention and control systems were not always effective.” from the report
Weak quality checks
seriousThe home's audits did not reliably identify cleanliness problems or make sure they were corrected. Outside professionals had also raised issues that were still waiting for action.
“The provider's governance systems had not effectively assessed, monitored or improved the quality of the service.” from the report
Night staffing
needs fixingStaff said night shifts were sometimes pressured and did not always reflect people's care needs. The provider was asked to review how staffing levels were decided, and an extra night staff member was later added.
“Staff told us that night staffing levels were sometimes pressured and did not always reflect people's true levels of care.” from the report
- 01What has been done to deep-clean the dining rooms, bathrooms, furniture and shower chairs identified in the report?
- 02How are clinical waste and personal protective equipment now being handled to prevent contamination?
- 03What changes have been made to governance audits, and can you show us evidence that previously identified premises problems have been fixed?
- 04How many staff are now rostered overnight, and how do you check that this matches residents' assessed care needs?
- 05What progress has been made with the new manager's application to register?
This inspection focused on concerns about cleanliness and infection control and rated Safe and Well-led; the other key-question ratings were not inspected during this visit and were carried over from the previous inspection. This explanation was written from the published report of 24 June 2023 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, April 2021
Lyons Court Care Home was rated Good; inspectors found safe, kind and improving care, with some care planning and assessment work still needed.
Inspectors visited on 7 April 2021 and carried out a focused inspection. They spoke with people, relatives and staff, observed care, checked the environment and reviewed medicines, care, staffing and training records.
The home was rated Good overall, with Safe, Effective and Well-led all rated Good. Inspectors found safe staffing, safe medicines systems, good infection control and improvements to the environment, training and management.
People were supported well with food, healthcare and activities. Relatives and staff described respectful care and a calmer atmosphere. However, some care plans and mental capacity assessments were not yet detailed or consistent enough, and positive behaviour support was still being embedded.
The overall rating improved from Requires Improvement at the previous inspection. This report only assessed Safe, Effective and Well-led. The other ratings were carried forward from the earlier comprehensive inspection.
Safe staffing
Inspectors found enough staff to meet people's needs. People and relatives said staffing had improved and that regular staff were available.
“There were safe staffing levels throughout the service.” from the report
Infection control
Staff used protective equipment correctly, and systems were in place to reduce infection risks, including COVID-19 risks.
“Staff wore PPE correctly, and there was plenty of securely held stocks.” from the report
Food and mealtimes
People's dietary needs were catered for and staff supported people well during meals.
“People were well supported by staff during mealtimes.” from the report
Improved leadership
The home had introduced better audits, training, supervision and staff support after earlier concerns. Staff said morale had improved and that the manager listened.
“The registered manager and provider had responded to concerns from our last visit regarding staff knowledge and support by providing additional training, focus groups and a more robust approach to debriefs and supervision.” from the report
Care plans were not fully consistent
needs fixingSome care plans did not give equally clear and detailed guidance, especially around positive behaviour support. The provider had identified this and was working to review all plans.
“Some care plans were more explicit and detailed than others.” from the report
Mental capacity records needed improvement
needs fixingStaff understood the Mental Capacity Act, but the assessment process and its records were not yet consistently clear or complete.
“Work was still needed to improve the understanding, quality and recording of the assessment process.” from the report
Medicine ordering changes were still being embedded
minorMedicines were managed safely, but the home was still putting agreed improvements to medicine stock and ordering into practice.
“The registered manager was continuing to embed changes that had been agreed with the local pharmacy and GP practice to improve medicine stock and ordering processes.” from the report
- 01How have you made sure all care plans give consistent, detailed positive behaviour support guidance?
- 02What further training has staff received on mental capacity assessments, and how do you check that records are complete?
- 03How are medicine stock levels and ordering monitored now?
- 04How do you check that staffing levels remain sufficient for people's changing needs?
- 05What recent changes have been made in response to feedback about activities and care?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not assessed in this visit and the other ratings carried over from the previous comprehensive inspection. This explanation was written from the published report of 22 April 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 Lyons Court Care Home
7 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- June 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2021Goodup from Requires improvementSafe: GoodWell-led: Good
- February 2020Requires improvementstayed Requires improvementSafe: Inspected but not ratedEffective: Inspected but not ratedWell-led: Inspected but not rated
- November 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- February 2018Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Good
- July 2017Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Inadequate
- January 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- June 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 16 December 2010.
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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