Lionsfield House

Updated 27 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

The inspection was undertaken by one inspector.

Service and service type

Lionsfield 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. Lionsfield 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.

What we did before the inspection

We reviewed information we had received about the service since they registered with CQC. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. We also used the information we had obtained during a direct monitoring approach call with the registered manager in June 2022. We used all this information to plan our inspection.

During the inspection

We spoke with one person about their experiences of the care provided. We spoke with five members of staff including the director of compliance, the registered manager and support workers. We reviewed one person’s care and medicines records and looked at three staff files in relation to recruitment. We also reviewed a range of records relating to the management of the service, including quality and safety audits and checks and some of the provider’s policies and procedures.

Updated 27 August 2022

About the service

Lionsfield House is a care home providing care and accommodation for up to 11 younger adults and older people with mental ill health needs. At the time of our inspection 10 people lived at the home. Accommodation is provided in an adapted residential property. Bedrooms are of single occupancy with ensuite facilities, with various communal spaces for people's comfort. The home also has a separate training flat to support people to transition towards independent living.

Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do, we also consider any wider social care provided. At the time of our inspection one person received support with their personal care.

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

The lack of provider oversight, during a period of management instability at Lionsfield House, meant staff had not received the support and guidance they needed and concerns relating to some aspects of quality and safety at the service had not been identified. Opportunities to improve service safety had been missed. The person, relatives and staff were encouraged to provide feedback about the service. Recent feedback showed high levels of satisfaction and feedback gathered had been used to drive improvement.

The person felt safe living in their home. However, risks associated with the person’s care and the environment, including fire safety, were not always identified, assessed and well-managed. Action was taken to address this. The prevention and control of infection was managed safely and in line with government guidance. Medicines were administered by trained staff. Shortfalls in the management of medicines had been identified. However, further monitoring was needed to ensure the remedial action taken to address the shortfalls were effective. Staff had been recruited safely and understood their responsibilities to keep people safe.

The person received the support they needed to access a range of health and social care professionals. The person was supported to have maximum choice and control of their life 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. Staff completed an induction and training to ensure they had the information, knowledge and skills to fulfil their role.

The person had formed positive relationships with staff. Staff knew the person well and were caring and respectful when providing support. However, some accepted practices within the home did not promote dignity and choice. Action was taken to address this. Confidential information was stored securely.

Assessments were completed to ensure people’s diverse needs were known and could be met prior to moving to the home. Action was planned to ensure care records provided staff with all the information they needed to deliver safe, personalised care. The person was supported to maintain relationships that were important to them and spent their time doing things they enjoyed. The service worked in partnership with other agencies to benefit the person. Staff understood their responsibilities in line with the with the provider’s complaints procedure.

The registered manager was committed to addressing shortfalls identified during the inspection visit and driving forward improvements.

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

Rating at last inspection

This service was registered with us on 25 February 2021 and this is the first inspection.

Why we inspected

This was a planned inspection 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 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 identified a breach in relation to the how the service was managed.

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.