Lilleybrook Care Home

Updated 31 May 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 2 Experts by Experience carried out the 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

Lilleybrook Care Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under 1 contractual agreement dependent on their registration with us. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

There wasn’t a registered manager in post. A new manager had been recruited in February 2023 and they planned to register with CQC.

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 considered the feedback from the local authority and professionals who work with the service. We used the information the provider sent us in March 2023 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 used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We spoke with 11 people who lived at Lilleybrook Care Home and with 9 people’s relative about their experience of the care and support provided by the service.

We spoke with 15 staff including the manager, the clinical lead, 2 nurses, 1 unit leader, 6 care staff, 1 chef, 1 maintenance worker, 1 housekeeper. and 1 activity co-ordinator. We also spoke with 2 representatives of the provider. We also spoke with 1 healthcare professional who visited the service.

We reviewed a range of records. This included 8 people's care records. A variety of records relating to the management of the service, including policies and procedures were also reviewed. We reviewed 4 staff recruitment and personnel files.

We continued to seek clarification from the management team to validate evidence found.

Updated 31 May 2023

About the service

Lilleybrook Care Home is a care home providing accommodation to persons who require nursing or personal care, for up to 60 people. The service provides support to older people and people living with dementia. At the time of our inspection there were 57 people using the service. People are accommodated in 1 adapted building, which has been divided into 3 households or ‘units’.

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

People and their relatives told us Lilleybrook Care Home was safe and staff responded to their needs safely. There were enough staff deployed to meet people’s needs. The management changed staffing levels depending on the occupancy of the home and people’s needs. Staff told us they had the skills, time and support they needed to meet people’s needs.

At the time of our inspection the provider was carrying out remedial fire safety works identified through a fire risk assessment. Immediately after the inspection work was carried out to ensure people were protected from risk.

People’s needs and choices had been assessed. Staff understood people’s individual risks and the support they required to maintain their health and wellbeing.

Incidents and accidents were reviewed to reduce the risk of reoccurrence. The management reviewed where accidents and incidents had occurred to identify and make improvements to the care they provided people. Staff were supported to reflect on incidents, complaints, and medicine errors to enable them to make improvements.

The provider had infection control procedures in place to protect people and prevent the spread of infection. Staff accessed personal protective equipment (PPE) and acted in accordance with government guidance. People’s visitors could visit in accordance with current guidance.

Staff supported people in the least restrictive way possible and in their best interests. Where people were living under Deprivation of Liberty Safeguards; staff understood the support they required.

People and their relatives told us there had not always been a wide range of activities, however more activities and support was now being provided. The manager and provider were aware of this concern and had recruited activity co-ordinators to start providing group and 1 to 1 activities.

The manager and provider operated effective systems to monitor the quality of care they provided to people living at Lilleybrook Care Home. There was a clear service improvement plan for the home based on the manager and provider's audits and knowledge of the service.

People, their relatives and staff spoke positively about the new management of the service and the improvements they had noticed. Staff told us they felt supported by the management team and felt they had the communication and guidance they needed.

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 25 January 2022).

Why we inspected

This inspection was prompted by a review of the information we held about this service. This included information of concern about people’s risk and the risk of choking. As a result, we undertook a focused inspection to review the key questions of safe, responsive and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

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

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.