Background to this inspection
Updated
10 July 2021
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 Care Act 2014.
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 one inspector.
Service and service type
Lisburne Court is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
The service had a manager registered with the Care Quality Commission. 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.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We asked the local authority and Healthwatch if they had any information to share about the service. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. We used all of this information to plan our inspection.
During the inspection
We spoke with five people who used the service and seven relatives about their experience of the care provided. We spoke with nine members of staff including the registered manager, the operations manager, the deputy manager, senior care workers, care workers, the housekeeping team and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.
We reviewed a range of records. This included three people’s care records and multiple medication records. We looked at two staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.
After the inspection
We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records. We spoke with three professionals who regularly visit the service.
Updated
10 July 2021
About the service
Lisburne Court is a residential care home providing personal and nursing care to 47 people aged 65 and over at the time of the inspection. The service can support up to 48 people.
Accommodation is provided across two floors which can be accessed via a stair-well and passenger lift. There are communal bathrooms, toilets and kitchen facilities as well as social, dining and garden areas that people can access.
People’s experience of using this service and what we found
People felt safe at Lisburne Court. People and relatives told us staff were kind and attentive. Risk assessments were carried out and incidents and accidents were investigated. Medicines were managed safely. We have made a recommendation about the provider’s ‘medication’ policy.
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. People’s needs were assessed, and care was delivered in line with their preferences and choices. Staff had completed additional training to support people’s nutritional needs. We have made a recommendation about the provider’s ‘nutritional and hydration needs’ policy.
The provider had developed a robust policy to strengthen the infection prevention and control (IPC) practices in the home. Staff complied with the requirements to wear protective personal equipment (PPE) and regularly washed their hands. The home was clean and tidy.
The management team completed effective audits and systems to monitor the quality of care at Lisburne Court. People, relatives and staff said the management team engaged with them positively.
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 was good (published 11 February 2020).
Why we inspected
The inspection was prompted by concerns raised by Her Majesty's Coroner. A Regulation 28 Report was issued to the CQC on 26 April 2021 relating to processes to identify risk and escalate care, pre-assessment processes and how effectively Lisburne Court worked with other agencies. The Coroners and Justice Act 2009 allows a Coroner to issue a Regulation 28 Report to an individual, organisations, local authorities or government departments and their agencies where the Coroner believes that action should be taken to prevent further deaths. A decision was made for us to inspect Lisburne Court and examine those risks.
We found no evidence during this inspection that people were at risk of harm from this concern.
Please see the safe, effective and well-led sections of this full report.
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.
We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Lisburne Court on our website at www.cqc.org.uk.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.