13 April 2023
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.
The inspection was completed by 2 inspectors 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.
Service and service type
Lightbowne Hall 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. Lightbowne Hall is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
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. The deputy manager had stepped up to the manager’s role and had been in post for 2 months. They had applied to register with the CQC. We are currently assessing this application.
Notice of inspection
This inspection was unannounced.
What we did before 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. 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 spoke with 8 people who used the service and 5 relatives about their experience of the care provided at Lightbowne Hall. We spoke with 15 members of staff including the manager, deputy manager, district manager, team leaders, care assistants and chef. We also spoke with 1 visiting professional.
We reviewed a range of records, including 7 people’s care records and multiple medication records. We looked at a variety of records relating to the management of the service, including quality assurance and incident reports.
We observed the support provided throughout our inspection and viewed the environment of the home.
13 April 2023
About the service
Lightbowne Hall is a residential care home providing personal care to up to 52 people. The service provides support to older people, some of whom are living with dementia. The home has 3 floors, each floor having their own lounge, dining area and adapted facilities. At the time of our inspection there were 47 people using the service.
People’s experience of using this service and what we found
We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. We considered this guidance as there were people using the service who have a learning disability and / or who are autistic.
People felt safe living at Lightbowne Hall. Risks were identified and guidance was in place to manage them. Additional details would improve the risk assessments for when people may become agitated. People received their medicines as prescribed. Thickeners used to reduce the risk of choking were not recorded when used. This was rectified during the inspection.
There were enough staff to meet people’s needs, although staff were busy on the ground floor due to people’s support needs. Staff were safely recruited. Equipment was regularly checked and serviced in line with legal guidelines. Incidents and accidents were reviewed for any learning to reduce further occurrences. The home was clean throughout, and infection control was well managed.
Staff had the training and support to carry out their roles. Staff said the management team were visible in the home and approachable if they needed to speak with them. People’s health, nutritional and hydration needs were being met. Referrals were made to medical professionals when required.
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.
People and relatives said the staff were kind, caring and respectful. Staff knew people’s needs and preferences. People’s cultural needs were met.
Care plans provided guidance for staff in meeting people’s needs. People and their relatives were involved in agreeing and reviewing their care plans. Two members of staff took the lead for arranging activities and trips out. Staff organised activities on each floor and had completed training for armchair exercises. People’s wishes for their care and support at the end of their lives was recorded.
A quality assurance system was in place. Regular audits were completed, and any actions identified assigned to a named person with agreed timescales for completion. The provider had oversight of the service through provider audits. Relatives said there was good communication with the staff team and any concerns they had were addressed. Staff said they enjoyed working at Lightbowne Hall.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
This service was registered with us on 6 May 2021, and this is the first inspection. The last rating for the service under the previous provider was good, published on 11 September 2019.
Why we inspected
This inspection was prompted by a review of the information we held about this service.
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.
We will continue to monitor information we receive about the service, which will help inform when we next inspect.