CQC report explained · a residential care home
What the CQC found at Lyons Gardens
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found effective arrangements for PPE, testing, visiting and temperature checks. They were only somewhat assured about managing infection outbreaks because some training was out of date and an infection-control audit and action plan were not available.
- Effective?
- Good
- This was not covered by this targeted inspection.
- Caring?
- Good
- This was not covered by this targeted inspection.
- Responsive?
- Good
- This was not covered by this targeted inspection.
- Well-led?
- Good
- This was not covered by this targeted inspection.
What inspectors found, January 2022
Inspected but not rated; inspectors found strong COVID-19 precautions but gaps in infection-control training and auditing.
This was an announced, targeted inspection on 7 January 2022. Inspectors looked at infection prevention and control, visiting arrangements and staffing pressures linked to COVID-19. They did not give an overall quality rating.
The home had measures for visitors, testing, temperature checks and personal protective equipment. People could also keep in touch with family and friends through video calls. Inspectors were assured that most infection-control arrangements were being followed.
There were some weaknesses. Some staff training was out of date because of staff absences and shift cover. The registered manager could not provide an infection-control audit and action plan. The home had asked the provider to temporarily stop emergency placements while staffing pressures continued.
Infection-control measures
Staff were observed wearing PPE correctly and following several practical infection-control measures.
“Staff were observed to be wearing their PPE correctly including face masks.” from the report
Testing and health checks
People and staff had regular COVID-19 testing and temperature checks.
“Staff were tested for COVID-19 twice a week and had rapid COVID-19 tests daily.” from the report
Keeping in touch
Staff supported people to use tablets and phones to keep in contact with family and friends.
“Staff supported people to use computer tablets and phones to video call and/or communicate with family and friends.” from the report
Visiting arrangements
Family and friends could visit in line with the guidance in force at the time, with testing, temperature checks and PPE.
“Family and friends could visit people who lived at the service in line with current guidance.” from the report
Out-of-date staff training
needs fixingSome staff training was out of date because staff absences meant people were covering shifts.
“The registered manager told us that due to staff absences, and staff covering shifts some staff training was out of date.” from the report
Missing infection-control audit
needs fixingThe registered manager could not provide an infection-control audit and action plan. This meant inspectors were only somewhat assured that the infection-control policy and outbreak arrangements were fully managed.
“The registered manager was unable to submit an infection control audit and action plan.” from the report
- 01Has all staff training that was out of date at the inspection now been completed?
- 02Has the infection-control audit and action plan been completed and reviewed?
- 03How are staff absences and agency or sister-home staff affecting staffing now?
- 04Are emergency placements still paused, and if so, when will they restart?
- 05How will visits, testing and PPE arrangements work for our relative and their family?
This was an announced targeted inspection of infection prevention and control, visiting arrangements and COVID-19-related staffing pressures; it did not assess the other four key questions or give an overall rating. This explanation was written from the published report of 29 January 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, November 2017
Lyons Gardens remained Rated Good; inspectors found safe, kind and personalised care, with some improvements still needed.
Inspectors visited without warning on 30 October 2017. They spoke with people, relatives, staff and a visiting health professional. They reviewed care records, medicines, staff files, training, complaints and management records.
The home was found to be safe, effective, caring, responsive and well-led. There were enough staff, medicines were managed safely, and staff understood safeguarding and people's rights. Care plans recorded people's needs, preferences and risks.
People were treated with kindness and respect. Relatives could be involved in care planning, and people were supported with health appointments, activities and links with the community. The service had a complaints process and monitored the quality of care.
The overall rating was Good, and all five areas were rated Good. This means inspectors found the service was meeting the relevant standards at the time of the visit. It had also been rated Good at the previous inspection in December 2015.
Safe staffing and medicines
Inspectors found enough staff to meet people's needs, with staff supporting people without rushing. Medicines were administered by trained staff whose competence had been checked.
“We saw that staff were busy but supported people in an unrushed manner.” from the report
Personalised care
Care plans included people's needs, preferences, interests and how they wanted support to be given. Relatives were involved in planning and reviews.
“These records contained enough information for them to deliver safe care.” from the report
Kind and respectful support
People and relatives spoke positively about staff. Inspectors found that staff promoted privacy, dignity and independence.
“People who used the service were cared for by staff in a kind and respectful way.” from the report
Staff training and health support
Staff had induction, training, supervision and appraisals. People were supported to attend appointments and maintain their health and nutrition.
“This showed us that staff were supported to provide effective care and support with regular training.” from the report
Feedback and improvement systems
People and relatives could give feedback and raise complaints. The manager used quality monitoring to identify improvements and record actions.
“The registered manager had a system in place to monitor the quality of the service provided.” from the report
One notification was missed
needs fixingThe manager told inspectors that one incident notification required by law had not been sent to the CQC. They said it would be submitted and that steps would be taken to prevent a repeat.
“The registered manager informed us about one notification that had not been submitted to the CQC since they had been in post.” from the report
Activities were being developed
minorThe manager identified increasing the activities available inside the home as an area for improvement. People were supported with some interests and community activities.
“One of the areas they had highlighted for improvement, and they were working on, was to increase the activities available for people within the service.” from the report
Previous rating display
minorThe previous CQC rating was not displayed using the correct template. This was corrected during the inspection.
“The rating of the previous CQC inspection was not displayed in the service using the correct template.” from the report
- 01What activities are now available inside the home, and how are they matched to each person's interests?
- 02How do you check that every incident that must be reported to the CQC is notified on time?
- 03How will my relative and our family be involved in setting up and reviewing the support plan?
- 04How do you check that staff remain competent to administer medicines?
- 05How are complaints and feedback recorded, investigated and used to improve care?
This was an unannounced inspection covering all five key questions; inspectors reviewed two people's care records and two staff recruitment files. This explanation was written from the published report of 25 November 2017 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 Gardens
2 rated inspections over 2 years: the service has held its Good rating throughout.
- January 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- November 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 7 January 2011.
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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39 live-in carers within about an hour of Peterborough
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,370 a week. 34 can care for a couple. 11 years' experience on average.
“I honestly feel lucky to have found her and have already booked her for another visit.”
“Magda was always positive and proactive about trying new things to keep dad busy. She also introduced new ideas for keeping dad healthy.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.