Lizbis Care Home

Lizbis Care Home is a care home registered to provide accommodation for people who require nursing or personal care relating to their health conditions, such as dementia, and frailty of old age. The service provides support for up to 19 people. At the time of our inspection there were 15 people using the service.

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

Systems in place to learn from incidents and drive improvement were not effective. Accident and incident forms lacked detail of actions which had been taken as a result, although knowledge of these incidents was present by the provider and registered nurses.

Not all environmental risks were managed. We found a fire door which had been wedged open when they should remain closed for safety, and the storage of people’s medicines required improvement.

People were not engaged in activities as much they wished, and some carers did not always speak to people with respect. We have made a recommendation about more effective ways to communicate with people.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. Not all Mental capacity assessments were decision specific and did not evidence how the determination of people’s ability to make decisions were made. People did not have the required deprivation of liberty safeguards in place.

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.

The provider was open and honest about the challenges which had been faced recently. They told us they were committed to improving the service and the support people required.

People and their relatives told us they felt safe living in the service and felt staff were responsive when they asked for help. Staff told us what person-centred care was and knew people well. Staff knew how to recognise signs of abuse and how to report these concerns. Policies and procedures were in place.

There were enough staff to meet people’s needs. Agency workers were used to cover shifts permanent staff were unable to commit to and these were regular workers so people could get to know them.

People’s care plans were reviewed regularly and updated so staff had access to the most up to date information to support people and people’s wishes for support at the end of their life were recorded.

Rating at last inspection

This service was registered with CQC on 10 January 2022 and this is the first inspection.

Why we inspected

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 inspection was prompted in part due to concerns received about staffing. A decision was made for us to inspect and examine those risks.

We have found evidence that the provider needs to make improvements. Please see all sections of this full report.

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

Enforcement

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 governance, dignity and respect and deprivation of liberty safeguards 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.