Lilbourne Court Nursing Home

Updated 12 April 2023

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

Two inspectors and an Expert by Experience completed this inspection. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Lilbourne Court Nursing Home 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. Lilbourne Court Nursing Home is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was not a registered manager in post. A new manager had been in post for 6 weeks and was in the process of completing their application to become registered with us.

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. We sought feedback from the local authority and professionals who work with the service such as Health Watch. 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 the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We made observations of how staff interacted with people. We spoke with 7 people and 4 relatives about their experience of the care and support provided. We spoke with 11 members of staff including the operations director, the new manager, the head of care, a nurse, 4 care assistants, 1 domestic staff member, 2 kitchen staff and the activities co-ordinator.

We reviewed a range of records. This included information contained in 6 people's care records and samples of medicine and daily records. We looked at 2 staff recruitment files and a range of records that related to the management and quality assurance of the service.

Updated 12 April 2023

About the service

Lilbourne Court Nursing Home is a care home providing personal and nursing care to up to 36 people. The service provides support to older and younger people living with a variety of conditions such as dementia, a sensory impairment, a physical disability or a mental health condition. At the time of our inspection there were 35 people using the service. Lilbourne Court Nursing Home accommodates people across three separate floors. One of these floors specialises in providing care to people living with dementia.

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

Risks to people’s safety were not consistently managed. This included risks associated with skin breakdown and epilepsy. Improvements were required to ensure recommendations from healthcare professionals to mitigate areas of risk were acted upon in a timely way.

People received their medicines as prescribed and overall, medicines were ordered, stored, administered and disposed of safely. However, medicine administration was not always recorded effectively. Improvements were required to the management of covert medicines, and medicines prescribed on a ‘when required’ basis.

People told us there were not always enough staff to meet their needs and preferences. At times, there was limited staff oversight of the communal spaces to ensure people remained safe. The new manager told us one of their key priorities was to review the staffing numbers to ensure they met the current needs of people living in the home.

Internal systems and processes were in place to check and monitor the quality of care provided. However, these had not always been used effectively. Some checks, in the absence of a registered manager, had not always been completed in line with the providers expectations. Some of the concerns we found, such as the management of risks to people’s health had not been identified by the providers own internal audits.

The new manager was open and transparent about areas they had already identified as requiring improvement. An action plan had been created by the new manager to drive forward the required improvements.

Some risks associated with people’s health and wellbeing had been identified, and records contained enough information to guide staff on what action to take to mitigate risks associated with areas such as catheter care and moving and handling.

Staff understood their responsibilities to protect people from the risk of abuse. Where people did raise concerns about their safety, action was taken to investigate and respond appropriately. The new manager understood their safeguarding responsibilities and had made appropriate referrals to the local authority as necessary.

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.

The home was clean and tidy. Staff followed good infection control processes.

People and relatives told us the home was well managed and spoke positively about the impact the new manager already had on the home.

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 requires improvement (published 6 March 2020).

Why we inspected

This inspection was prompted by a review of the information we held about this service which indicated improvements had been made since our last inspection. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

We have found evidence that the provider still needs to make improvements. Please see the safe and well-led sections of this full report. The overall rating for the service has remained requires improvement following this inspection.

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.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Lilbourne Court Nursing Home on our website at www.cqc.org.uk.

Enforcement

We have identified a breach of regulation in relation to good governance 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.