Lyle House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Our rating for the "Safe" key question has improved from "Requires Improvement" to "Good" based on our recent assessment. More details will be provided in the evidence category sections. Lyle House demonstrated a strong commitment to safety. A well-established culture of learning ensured that staff and managers received regular training, and lessons learned were shared in meetings. The service effectively assessed people’s needs before admission, involving residents, families, and healthcare professionals in the process. Staffing levels were adequate, with enough staff and managers present throughout the day and night. Recruitment processes were thorough, ensuring that staff were well-suited to their roles. Ongoing training, supervision, and appraisals equipped staff to meet people’s needs safely. Safeguarding procedures were followed rigorously, with the manager engaging with the local authorities and the Care Quality Commission (CQC) when incidents occurred. People were involved in managing risks through comprehensive and regularly updated assessments. The care home environment was safe, with regular health and safety checks conducted. Infection control measures were strictly adhered to, with proper use of personal protective equipment (PPE) and hygiene practices. Medicines were safely managed by trained senior staff. Overall, Lyle House provided a secure environment where residents received good quality care.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People were generally safe in their environment. People felt free to talk openly about their experiences. A person said that they were always respected and spoken to kindly. They mentioned that the staff were always ready to support them whenever they needed help. People who used the service experienced positive and engaging interactions with their care team. The care team was keen to promote independence and engaged people in meaningful activities based on the choice of the person.

Staff described ways in which learning and improvement was passed down to the staff team. A staff member said, “I do the falls analysis every month, whatever I come across as a trend, I will discuss with the senior team and do supervision with staff if needed.” “We also have serious concern meetings, where we discuss any learning.”

The provider had established comprehensive procedures for assessing and managing risks to people. These processes involved regular risk assessments, which were reviewed and updated as needed to ensure they remained relevant and effective. Staff were actively involved in these assessments, ensuring that they were well-informed about the specific risks associated with each person.

People who used the service had a positive experience with the staff. They felt their independence were promoted and their choices were always respected. A person stated that they felt comfortable at Lyle House and had confidence in the staff to support them with anything they needed.

A staff member described how the process for new referrals took place. They said, “Our customer relationship manager (CRM) will get referrals, we do the assessment and meet them in person. I will check their needs and see if we can meet them after discussing with the manager, agree a move in date.” “The move in date involves the CRM and the seniors. People are given the opportunity to come and visit before deciding.”

Staff described how they worked in partnership with external healthcare professionals to ensure people’s needs were met. They said, “If there are any skin issues we liaise with the district nurses, we can also call the GP and the care Home InReach Team. They gave an example of how they supported a person to access dental services after they had asked for a consultation. "A few months ago the InReach team gave us some training around pressure sores" Staff told us that all the people who used the service, apart from those on respite care, were registered with one GP practice. This helped with familiarity. They told us the GP visited the care home every week.

The provider had established clear pathways for residents transitioning into the service. These pathways ensured that all relevant information was communicated effectively between different teams and professionals involved in people's care. This collaborative approach helped to minimise risks associated with transitions and ensured continuity of care.

We spoke to people who used the service, and they expressed that they felt safe in the care home. They felt confident that they could report their concerns and that these would be dealt with. The home used a ‘resident of the day’ format as part of their key working process. This format captured people’s views, opinions, and choices and provided an opportunity for people to make complaints. Incidents were acted upon very quickly and escalated to external professionals and the local authority in a timely manner.

Staff were aware of safeguarding and the steps they would take to report any concerns. Some of the staff said: “Safeguarding is making sure residents are safe from harm, making sure the environment is safe.” “I would report any concerns to the senior on the floor, if it’s the senior otherwise the deputy.” “Safeguarding is the way we protect the vulnerable – I would tell the senior what I have observed, if they don’t do anything I will remind them and report to the manager and then I can blow the whistle.”

Staff demonstrated a clear understanding of their responsibilities regarding safeguarding. They were vigilant in identifying and reporting any concerns or incidents that could potentially harm people. We noted that staff were well-trained in safeguarding procedures, and they felt confident in their ability to protect people from abuse or neglect.

When incidents occurred, the manager engaged with the local authority safeguarding professionals and notified the Care Quality Commission (CQC). The outcome of safeguarding investigations were shared with people and relatives and plans of action were created to prevent reoccurrence.

People who used the service were actively involved in managing risks related to their care. Staff worked closely with people to ensure that their risk assessments were person-centred and reflective of their unique needs and preferences. People and their families were encouraged to participate in discussions about risk management, giving them a voice in decisions that affected their safety and well-being. A person who was on respite expressed a desire to continue living in the care home, highlighting the positive impact of the care and support provided.

Staff we spoke with were aware of the risks to people and how they supported people to manage these. They said, “We have residents with higher risk of falls. We discuss these at handover, they (staff) have access to the care plans.” They gave us examples of how they supported particular people. They described a person who used a Sara steady and mobilised with a Zimmer frame. They had a sensor mat and a call bell which reduced the risk of falls. “We have post fall observations and discuss in the flash meetings.” Another staff member said if they came across any pressure sores, they would inform the GP, update the skin integrity records and send referral to the Tissue Viability Nurse (TVN).” “We are doing as much as we can to keep people as safe as possible.” Staff told us the handover meetings they held every day was a useful way in which risks to people were discussed and used to inform about any new risk. “The main handover is downstairs with the seniors and then we have a unit handovers.” Staff told us if they came across any incidents they would “Report to the senior, include in handover, seniors do the reporting to the relevant professionals, we monitor and record all interactions on Nourish.” “We record adverse events on Nourish.” “The handover is very good, we understand what the issues are.”

On the day we inspected, there was an incident that had been handed over by the night care team. The team leader on the day shift worked with the resident to ensure a safe and supportive approach to managing the risks. An incident report was written, the GP was contacted, and a follow-up call was made by the team leader on shift. The family was informed of the incident, and reassurance was provided. Risk assessments were up to date and captured the involvement of residents, families, and external professionals. Residents were reviewed from time to time and were involved in regular key working.

People’s risks were assessed and people participated in their risk assessments. Risk assessments covered a range of areas including falls, safe swallowing and the environment. These were regularly reviewed to ensure they remained relevant and continued to mitigate risks. When required, the manager made referrals to health and social care professionals who undertook risk assessments and provided staff with guidance to follow to keep people safe.

We spoke to people to understand how they felt about the environment in which they received care. People confirmed that they were happy and felt safe. A person who required full hoisting told us that their equipment were always maintained and, when there was a fault, it was dealt with in a timely manner.

Staff told us they had enough equipment, such as hoists, to keep people safe.

During our visit, we observed that the care home environment was well-maintained and safety protocols were being followed. There were radiator covers installed. Health and safety checks were visibly conducted by the maintenance staff. We observed that the care home was clean and dementia-friendly based on the choices of the individual. Residents had photographs on display on their doors as per their choosing. Carpets were free from malodour and trip hazards. People could be observed walking around freely using handrails. There were window restrictors in place. We also observed that there was a keypad entry system in place designed to keep people safe.

The environment of the care home were kept safe through regular and thorough processes. There were maintenance schedule in place which were followed by all staff; monitored and audited by the manager. Equipments were regularly serviced, and a log was kept.

On the day we inspected, people told us that they felt the staffing level was great and worked well for them. People who used the service always had staff available in the lounge, ensuring that no one was out of sight.

The manager told us there were senior care workers allocated to each floor and there were 2 deputies covering 2 floors each. In addition, there was a Wellbeing team, Housekeeping team and Front of House team. The division of staff into the care team, front of house team and housekeeping team helped to allocate duties effectively. This meant the relevant staff teams were able to focus on their particular areas. Staff we spoke with told us that staffing levels had improved and there were enough staff to meet the needs of the people. Comments included, “The staffing levels are enough”, “We used to have some issues with staffing but the manager has sorted it”, “1 carer to 5 residents here (on this floor) is fine”, “The staffing levels are OK, the residents are quite capable.” Staff said they had an allocation when they came onto shift so they knew which floor they were on and which rooms they were responsible for. “We and the senior discuss the allocation and work out who we need to support first. We focus on the double up first.” “When we come in the morning we get our allocation about the floor we are on.” “We always have 1 person in the lounge with other residents and the Front of House team help us to feed the residents.” Managers told us they used a dependency tool which was reviewed every month to work out safe staffing levels. Staff told us the quality of training was good and they had regular supervision and observations. “We get regular training, mixture of online and face to face.” “We get good training , when courses are due to be renewed we get an alert.” “My last supervision was around 2/3 months ago.” “We also do staff observation, this includes mealtime audit, dignity audit, moving and handling audit and also personal care and general observation.”

Lyle House maintained a safe staffing level across all floors. Each floor had a designated team leader who was responsible for the administration of medicines and provided additional support to other staff. We observed lunchtime service, and it was well managed by the staff and the front of house team.

The manager ensured that there were enough staff and managers on each floor of the service throughout the day and overnight to keep people safe. The provider used safe and robust recruitment processes to ensure that staff were suitable to provide care and support. Staff received on-going training, supervision and appraisal to ensure they had the skills required to meet people's needs and to keep them safe.

People expressed satisfaction with the cleanliness and hygiene standards at the care home. People who used the service noted that the home was consistently free from malodours.

We spoke with members of the housekeeping team who told us they had all the equipment needed for good infection control. We observed housekeeping staff on each floor, they maintained the cleanliness of the environment. A staff member said their daily duties included cleaning all the bedrooms and the communal areas on the floor they had been allocated to. The environment was clean and free from malodours. A staff member said that ‘I have never lacked any Personal Protective Equipment (PPE) for my job’.

We observed the care home to be clean with no malodours. Staff followed safe practices when supporting people to prevent the risk and spread of infection. This included wearing personal protective equipment, including gloves and aprons and regularly using hand sanitiser. People looked well-kempt and clean. Staff were clean, and the home had a housekeeping team in place who were observed using the correct Personal protective Equipment (PPE) across the service. Clinical wastes were disposed of in designated bins. There were instructions on handwashing techniques in bathrooms. The home had a 5-star rating in food hygiene. Doors and handles were free from grime. Bathrooms had no malodour.

The care home maintained a strong focus on infection control through its housekeeping processes. Housekeeping staff were equipped with all the necessary tools and materials to perform their duties effectively, including ample access to Personal Protective Equipment (PPE). Daily cleaning routines were structured, with staff responsible for maintaining cleanliness in both individual bedrooms and communal areas. The environment was consistently clean, and regular checks ensured that the home remained free from malodours, supporting a safe and hygienic living space for people.

People had their medicines on time and in a respectful manner. People responded well to the staff and expressed that they had a positive experience. All medicines were available and as required protocols were in place. Medicines were safely stored, and keys were kept with the team leader in charge of medicines. During medicine administration periods, we observed that the staff wore different vests visible to all persons, indicating it was time for medicines to be administered.

Staff confirmed that only senior staff members were trained to administer medicines. They told us they had completed the necessary training for this and undergone a competency assessment. Deputy managers carried out regular checks to ensure senior staff members were competent in medicines administration.

A clear process was observed for the safe handling of medicines. The team leader on shift ensured all medicines were administered safely and on time. Deputy managers carried out regular checks to ensure senior staff members were competent in medicines administration. There were policies and procedures in place. Medicines were stored safely and correctly, with temperatures monitored. Keys were kept safe and with a responsible staff designated for medicines safety. Persons with as-required medicines had a protocol to support this. Creams were labelled when opened, and staff had a good knowledge of the side effects of each medicines and what each medicines was for. People received their medicines from senior staff who were trained to administer medicines. A person had a covert medicine plan in place with all the relevant best interest meetings documented and signed by a qualifying health professional.