We carried out a review of the data available to us about Lillibet Lodge on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Lillibet Lodge, you can give feedback on this service.
We found the following examples of good practice.
¿ Measures were in place to help ensure that visitors did not bring COVID-19 in to the service. These included showing proof of a negative lateral flow test (LFT) and proof of vaccination against COVID-19.
¿ Staff were trained to use Personal Protective Equipment (PPE) correctly. We observed staff wearing appropriate PPE depending on the support they were giving people.
¿ The registered manager provided separate clothing for staff to change in to and use when working in the service and this clothing was also laundered at the service. This helped reduce the spread of COVID-19 in and out of the service.
¿ Cleaning schedules were in place and domestic staff told us they had enough time to complete their allocated duties. The service looked clean and people told us they felt the service was well maintained.
¿ The management team had adapted the service to help promote social distancing. This included a pod which visitors used to see their families and a dividing wall put up in one of the lounges.
¿ People and staff took part in regular testing to ensure they identified if they were COVID-19 positive and could take measures to prevent spreading the infection.
¿ People had been supported to have visitors come to the service in line with COVID-19 restrictions and guidelines. When face to face visits were not able to go ahead people were supported to stay in contact using telephone and video calls.
¿ The management and staff team helped ensure that people's wellbeing was maintained throughout the COVID-19 pandemic. This included purchasing various items and activities tailored to people's preferences, social interests and past times.
Lillibet Lodge is a residential care home, providing care and support to older people living with a variety of health conditions. Most people were living with dementia. At the time of the inspection, 24 people were living at the service.
People’s experience of using this service:
People, relatives and staff said people’s needs were met by the service. Further improvements had been made to the provider’s quality monitoring processes since our previous inspection. This ensured people now received safe and effective care. However, improvements were required to ensure respectful language was always used to describe people’s needs. More work was necessary so that people were always supported to take part in activities that were meaningful to them.
People were protected from harm by staff who were confident in recognising and reporting concerns. People were safe because potential risks to their health and wellbeing had been managed well. There were enough staff to support people safely. People were supported well to take their medicines. Lessons were learnt from incidents to prevent recurrence. Staff followed effective processes to prevent the spread of infections.
Further training had ensured staff had the right skills and knowledge to meet people's needs effectively. Staff had the information they required to meet people’s assessed needs. People had been supported to have enough to eat and drink. People had access to healthcare services when required. This helped people to maintain their health and well-being.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The policies and systems in the service supported this practice. People were involved in making decisions about their care and support. Staff supported people in a way that respected and promoted their privacy and dignity. They encouraged people to be as independent as possible.
People were happy with how staff supported them to meet their individual needs. They said this had been done in a compassionate and person-centred way. Complaints were managed well and there was learning from these to reduce the risk of recurrence. The service provided good end of life care when required. Further work was necessary to ensure people's end of life care wishes were included in their care plans.
Rating at last inspection:
The last rating for this service was Requires Improvement (published 08 June 2018).
Why we inspected:
This was a planned inspection based on the previous rating.
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.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk.
Lillibet Lodge can accommodate up to 25 older people who have a range of care needs including dementia, mental health, physical disabilities and sensory impairments. Long-term placements as well as respite and / or rehabilitation needs are catered for. The accommodation is arranged over three floors and can be accessed using a passenger lift. There are two communal areas, accessible outside space and 23 bedrooms - two of which are shared rooms. At the time of this inspection there were 21 people living at the home.
A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
At the last inspection on 14 February 2017, the home was rated Requires Improvement. During this inspection, which took place on 24 April 2018, we found the home remained Requires Improvement. This is the second time the service has been rated Requires Improvement. Despite this, there was evidence of real progress being made in all the areas we identified for improvement at the last inspection. The registered manager and provider have accepted our findings from this inspection and have already sent us a plan which includes appropriate actions to address all of the areas we identified for improvement on this occasion. We will carry out another inspection in due course, to check their progress with the actions they have proposed to take.
Systems were in place to ensure people received their medicines in a safe way however, these were not followed on the day of the inspection. The registered manager took swift action to ensure this didn’t happen again.
People were protected by the prevention and control of infection but more work was needed to ensure the home was free from offensive odours. The registered manager had already taken steps to address this, including appointing a member of staff to carry out deep cleaning in the home.
The provider carried out checks on new staff to make sure they were suitable and safe to work at the home. However, changes were needed to ensure all required employment checks were carried out for new staff before they started working at the home. We found a small number of checks were missing, such as unexplained gaps in employment history.
Staff received training to support them in their roles, but work was needed to improve the quality of the training provided. Staff we spoke with confirmed they had received training but were unable to articulate their learning adequately.
People were supported to eat and drink enough, but improvements were needed to enhance their enjoyment of the food provided, and to ensure that people’s dietary and religious needs were always adhered to. We observed someone being given something to eat that they should not have been given. Once again, the registered manager took swift and responsive action to address this. Risks to people with complex eating and drinking needs were being managed appropriately.
People were protected from abuse and avoidable harm. Staff had been trained to recognise signs of potential abuse and knew how to keep people safe. Processes were also in place to ensure risks to people were managed safely.
Improvements had been made to ensure there were sufficient numbers of suitable staff to keep people safe and meet their needs.
There was evidence that the home responded in an open and transparent way when things went wrong, so that lessons could be learnt and improvements made.
The building provided people with sufficient accessible space and modified equipment to meet their needs.
The home acted in line with legislation and guidance regarding seeking people’s consent, but more work was planned to ensure best interest decisions were recorded for anyone sharing a bedroom.
People received care and support that promoted a good quality of life and was delivered in line with current legislation and standards.
Staff worked with other external teams and services to ensure people received effective care, support and treatment. People had access to healthcare services, and received appropriate support with their on-going healthcare needs.
Staff provided care and support in a kind and compassionate way. People were encouraged to make decisions about their daily routines. This meant that people were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.
People’s privacy, dignity, and independence was respected and promoted. They received personalised care and were given opportunities to participate in activities, both in and out of the home. More work was planned to ensure that activities were meaningful for everyone living at the home.
Arrangements were in place for people to raise any concerns or complaints they might have about the home. These were responded to in a positive way, in order to improve the quality of service provided.
Systems were in place to support people at the end of their life to have a comfortable, dignified and pain free death.
There was strong leadership at the home which promoted a positive culture that was person centred and open. Arrangements were in place to involve people in developing the service.
Improvements had been made to monitor the quality of service provision, in order to drive continuous improvement.
Opportunities for the service to learn and improve were welcomed and acted upon, and the service worked in partnership with other agencies for the benefit of the people living there.
Lillibet Lodge is a residential care home providing a service for up to 25 adults, who may have a range of care needs, including physical disabilities, mental health, dementia and sensory impairments. There were 24 people living at the service on the day of the inspection.
A new manager was in post who had applied to register with us, the Care Quality Commission. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
We found some areas that required improvement:
Staff had the right skills and knowledge to meet people’s needs. However, people told us they were often left waiting for help when they called for assistance, and records we looked at supported this.
Care plans had been developed to record how people wanted to receive their care and support. However, these sometimes lacked important information about the person involved, or they were not followed consistently.
People were given opportunities to participate in meaningful activities when staffing levels allowed for this. This meant that there wasn’t a regular programme of activities, particularly for those people who were not able to, or chose not to, leave their rooms.
Systems were in place to monitor the quality of the service provided and drive continuous improvement. However, these were not always effective because we found that concerns identified during this inspection had not always been picked up within audits that had been carried out.
The manager and provider acknowledged our findings and following the inspection, provided an action plan and clear assurances that all these areas would be addressed.
We also identified many areas during the inspection where the service was doing well:
Staff had been trained to recognise signs of potential abuse and keep people safe. People felt safe living at the service and staff were confident about reporting any concerns they might have.
Processes were in place to manage identifiable risks within the service to ensure people did not have their freedom unnecessarily restricted.
The provider had carried out appropriate checks on new staff to make sure they were suitable to work at the service.
Systems were in place to ensure people’s daily medicines were managed in a safe way.
Staff had received training to carry out their roles, including support to complete nationally recognised induction and health and social care qualifications.
People were supported to have choice and control of their lives and staff supported them in the least restrictive way possible.
Systems were in place to ensure the service worked to the Mental Capacity Act 2005 key principles, which state that a person's capacity should always be assumed, and assessments of capacity must be undertaken where it is believed that a person cannot make decisions about their own care and support.
People had a choice of food, and had enough to eat and drink. Assistance was provided to those who needed help with eating and drinking, in a discreet and helpful manner.
The service worked with external healthcare professionals, to ensure effective arrangements were in place to meet people’s healthcare needs.
Staff provided care and support in a caring and meaningful way. They treated people with kindness and compassion and respected their privacy and dignity at all times.
We saw that people were given opportunities to express their views on the service they received and to be actively involved in making decisions about their care and support.
A complaints procedure had been developed to let people know how to raise concerns about the service if they needed to. People were confident in raising concerns if they needed to do so.
The new manager provided effective leadership at the service, and promoted a positive culture that was open and transparent. Everyone felt she was approachable and fair.