Lillibet House

Updated 26 August 2022

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 carried out by two inspectors and an 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

Lillibet 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. Lillibet 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 service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

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

Notice of inspection

This inspection was unannounced.

Inspection activity started on 4 July 2022 and ended on 29 July 2022. We visited the location’s service on 4 July 2022.

What we did before the 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 with two people living at the service. We spoke with nine people’s relatives. We spoke with nine staff including the provider, registered manager, deputy manager, care consultant and care staff.

We reviewed a range of records. This included eight people's care records and medication records. We looked at 12 staff files in relation to recruitment, training and supervision. A variety of records relating to the management of the service including audits, policies and procedures were reviewed.

Updated 26 August 2022

About the service

Lillibet House is a residential care home providing accommodation and personal care to up to 30 people, most of whom were living with different types of dementia. At the time of our inspection there were 25 people using the service.

The home is built over three floors. All bedrooms have a wash hand basin, shared toilets and bathrooms are located on each floor. In addition, there are shared living areas on the ground floor and first floor of the home. The care home has a private garden with a summer house available to people, their relatives and friends.

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

Since the last inspection the provider had engaged with a care consultant to support with addressing shortfalls within the service. Protecting people from potential harm and abuse had improved. However, further work was required to ensure information within risk assessments provided guidance and direction to staff to reduce risk.

We received mixed feedback from relatives regarding the staffing levels in the service. Following the last inspection, the provider had reviewed the staffing levels and made amendments to the deployment of staff in the home. In addition, a recruitment drive was ongoing, and several new staff had joined the staff team. People appeared to be comfortable and relaxed with the staff in the service. Staff treated people with dignity and respect. Social engagement had improved since the last inspection and staff were observed encouraging people to participate in activities of their choice.

Staff received an induction which prepared them for their role. Staff told us they had completed additional specialist dementia training which had enhanced their understanding. One staff member told us, “The training provided a real insight into how a person living with dementia feels. It has made me think more about how I support people as well as refreshing my understanding of dementia.” Staff felt supported by the registered manager, who they found to be approachable and visible in the service.

Cleaning schedules had been reviewed within the service. The service was visibly clean with no mal odour. A system was in place to reduce the risk of transmission of communicable disease. Staff and visitors had access to face masks, gloves and aprons.

Following the last inspection, the quality assurance system had been reviewed and additional checks had been implemented to identify and address shortfalls within the service. This required further time to evidence that processes were embedded within the service to sustain improvements.

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 did not support this practice.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. We considered this guidance as there were people using the service who have a learning disability and or who are autistic.

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

Rating at last inspection and update

The last rating for this service was inadequate (published 26 January 2022). The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found improvements had been made and the provider was no longer in breach of some regulations. However, not enough improvements had been made in other areas and the provider was still in breach of the associated regulation.

This service has been in Special Measures since 19 January 2022. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

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.

The overall rating for the service has changed from inadequate to requires improvement based on the findings of this inspection.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Lillibet House on our website at www.cqc.org.uk.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to risk assessments at this inspection.

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

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.