Lychgate House

Updated 31 May 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was completed by 1 inspector and 1 Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Lychgate House is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Lychgate House is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke to 4 people and 7 relatives about their experience of care provided. We used observations to gather evidence of people’s experiences within the service. We spoke to 4 members of staff, including the registered manager, and the director.

We reviewed 3 people’s care files, a range of medications records, and 3 staff files in relation to recruitment. We also reviewed a range of documents relating to the management of the service, including policies, procedures, and a range of quality audits. After the inspection we received additional information from the provider, as requested.

Updated 31 May 2023

About the service

Lychgate House is a residential care home providing personal care to up to 15 people. The service provides support to people who have mental health needs. At the time of our inspection there were 15 people using the service.

People’s experience of using this service and what we found

People were not always safeguarded from harm as systems were not in place to protect them. The provider did not have robust processes in place for the oversight of the service to identify concerns and make improvements. Some areas of the environment were unhygienic, or poorly maintained, and in need of renovation to make it safe and comfortable for people living in the service. Infection control measures were not always adequate and placed people at risk.

Care plans were regularly reviewed and contained information on how to support people, however, these were task focused, and language used throughout was negative.

We have made a recommendation the provider seeks guidance on person-centred care planning.

Staff were recruited safely, had received appropriate training and an induction to the service. There were enough staff to meet people’s needs. Medicines were well managed, and safely administered by trained staff. Staff treated people with kindness and compassion and encouraged people’s independence while maintaining their dignity.

People told us they enjoyed living at Lychgate House. People were supported to maintain relationships with their relatives and loved ones. Relatives and loved ones told us the staff team keep them regularly updated on changes with peoples health and support needs. People were able to maintain access to the community should they wish, such as going to the pub, or out with family.

The service supported people to access healthcare services, and to receive ongoing healthcare support if required, including external professionals like GPs and pharmacists. People enjoyed a varied menu and were encouraged to help themselves with access to drinks and snacks between meals.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service under a previous provider was good (published 17 May 2019).

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Enforcement

We have identified breaches in relation to good governance, safeguarding of service users, and infection prevention and control at this inspection.

Please see the action we have told the provider to take at the end of this report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.