16 February 2023
During an inspection looking at part of 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.