Archived: Lillibet Lodge

Updated 15 January 2016

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection was unannounced and took place on 25 November 2015. It was carried out by one inspector 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.

Before the inspection, we checked the information we held about the service and the provider, such as notifications. A notification is information about important events which the provider is required to send us by law. In addition, we asked for feedback from the local authority, who have a quality monitoring and commissioning role with the service.

During the inspection we used different methods to help us understand the experiences of people using the service, because some people had complex needs which meant they were not able to talk to us about their experiences.

We spoke with five people living in the home and observed the care being provided to the majority of people at some point during the day, including lunch time and when medication was being administered. We also spoke with the registered manager, the provider, deputy manager, three care members of staff - including one senior, the cook, the administrator, the housekeeper and four relatives / visitors.

We then looked at care records for three people, as well as other records relating to the running of the service - such as staff records, medication records, audits and meeting minutes; so that we could corroborate our findings and ensure the care being provided to people was appropriate for them.

Updated 15 January 2016

This inspection took place on 25 November 2015. It was unannounced.

Lillibet Lodge is registered to provide a service for up to 25 people, who may have a range of needs, including old age, physical disabilities, mental health, dementia and sensory impairments. Nursing care is not provided. During this inspection, 24 people were living in 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.

There were sufficient numbers of suitable staff. However, improvements were required to ensure the way staff were deployed ensured peoples’ safety and met their individual needs.

Systems were in place to ensure people’s daily medicines were managed in a safe way and that they got their medication when they needed it. However, improvements were required to ensure staff checked people had received their creams as prescribed, before recording these as given.

People had enough to eat and drink. Assistance was provided to those who needed help with eating and drinking, in a discreet and helpful manner. However, improvements were needed to enhance people's dining experience, and to ensure all staff are familiar with people's dietary preferences.

We saw that people were given opportunities to be actively involved in making decisions about their care and support. However, improvements were required to ensure records relating to people's care are up to date and contain sufficient detail, to demonstrate the care and support being provided.

Systems were in place to monitor the quality of the service provided. However, improvements were required to ensure these are more effective, in order to drive continuous improvement within the service.

Staff had been trained to recognise signs of potential abuse and keep people safe. People felt safe living at the service.

Processes were in place to manage identifiable risks within the service, and ensure people did not have their freedom unnecessarily restricted.

The provider carried out proper recruitment checks on new staff to make sure they were suitable to work at the service.

Staff had received training to carry out their roles and meet people’s assessed needs.

We found that the service worked to the Mental Capacity Act 2005 key principles, which meant that people’s consent was sought in line with legislation and guidance.

People’s healthcare needs were met. The service had developed positive working relationships with external healthcare professionals to ensure effective arrangements were in place to meet people’s healthcare needs.

Staff were motivated and 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.

People’s social needs were provided for and they were given opportunities to participate in meaningful activities.

A complaints procedure had been developed to let people know how to raise concerns about the service if they needed to.

There were effective management and leadership arrangements in place.