6 June 2023
During an inspection looking at part of the service
Lilybank Hamlet Care Home is a residential care home providing personal care to up to 63 people. The service provides support to people with dementia, older people and people with a learning disability. At the time of our inspection there were 32 people using the service.
The home is set over 3 floors with a lounge, dining room and conservatory on the ground floor and further communal spaces to the second floor. There was a mixture of ensuite and shared bathroom facilities and there was access to outdoor space.
People’s experience of using this service and what we found
We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.
Right Care: Identified risks to people's safety were not always mitigated to keep people safe from avoidable harm. Governance systems were not effective in monitoring risks to the health, safety and welfare of people using the service.
Systems and processes were not effective in maintaining and inspecting equipment accessories used to lift people. Medicines were not always managed safely; medicine protocols were not always in place for the administration of when required medicines. Fire safety actions were not completed, fire procedures were not updated, evacuations were not reviewed with actions to improve, and staff had not been trained in the use of fire equipment.
People received kind and compassionate care. Staff protected and respected people's privacy and dignity. Family members felt that their relatives were safe at the service. Appropriate checks were carried out when recruiting new staff to support people. People could take part in activities and were supported to access their community.
Right Culture: The service had recently gone through several changes, including a change of leadership. More time will be required to assess whether the leadership in place ensures people have inclusive and empowered lives. People felt able to raise concerns and felt that the management team were approachable.
Right Support: Staff had received training to support people with a learning disability. The provider recently closed a small home at the location and supported peoples transition into other placements or into the main home. The provider had worked with other agencies to coordinate and plan the transitions for people.
People were supported to have maximum possible 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 service did not always demonstrate how they were meeting the principles of right support, right care, right culture.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was requires improvement (published 17 March 2023).
At our last inspection we found breaches of the regulations in relation to safe care and treatment and governance. The provider completed an action plan after the last inspection to tell us what they would do and by when to improve.
At this inspection, we found the provider remained in breach of regulations.
Why we inspected
We carried out an unannounced comprehensive inspection of this service on 06 June 2023. Breaches of legal requirements were found in relation to safe care and treatment and good governance.
We undertook this focused inspection to check if the provider had made improvements and if they were now meeting the legal requirements. This report only covers our findings in relation to the key questions Safe and Well-led.
For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.
The overall rating for the service has not changed following this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Lilybank Hamlet Care Home on our website at www.cqc.org.uk.
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.
Enforcement
We have identified continued breaches in relation to health and safety, fire safety, governance and medicines management.
Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.
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.