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We are carrying out a review of quality at Libury Hall. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary

Overall summary & rating


Updated 11 January 2017

Libury Hall is registered to provide residential care for up 37 older people living with mental health needs. At the time of our inspection 32 people were living at Libury Hall.

The inspection took place on 22 November and 07 December 2016 and was unannounced. At our previous inspection on 08 November 2015 we found breaches of regulations 09, 12, and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because risk assessments had not been completed to safely manage identified risks of harm to people or others.

The registered manager had not sufficiently investigated and reviewed incidents to ensure people were kept safe. People’s medicines had not been safely managed. People were not always able to influence or contribute to their care, and people’s social needs were not consistently met.

Management systems and processes were not effectively established or operated to ensure people received a safe and high quality service, and records of care did not detail how people needed to be supported.

At this inspection we found significant improvements had been made in areas relating to managing risk, administering and management of medicines, supporting and developing staff, meeting people’s individual needs, and some improvements relating to the management of the service were found. However we also found improvements were still required in governance systems to ensure the service was well led and records relating to people's care were accurate.

Staff we spoke with were knowledgeable in relation to keeping people safe from harm and reporting incidents to the management. Risks to people’s well-being were managed positively by staff in a manner that promoted people’s choice and independence. People were supported by sufficient numbers of staff who responded promptly when they required assistance. People were supported by staff that had undergone a robust recruitment process to ensure they were of good character. People's medicines were managed safely as intended by the prescriber and staff had received appropriate training to do so.

Staff felt supported by the registered manager and management team who enabled them to carry out their role effectively. Staff had received training relevant to their role and further training for specialist areas had been identified and organised. People's consent had been sought prior to care being carried out and staff took time to talk to people to gain that consent. People's nutritional needs were met and their food and fluid intake and weight were monitored and people were able to choose what they ate from a varied menu. People`s health needs were met when needed with access to a range of health professionals when needed.

Staff spoke with people in a kind, patient and friendly way and respected people’s dignity. People felt listened to and told us they felt they could shape their own care to reflect their own personalised choices. Staff were aware of people's needs, choices and we saw that a friendly rapport had developed between people and staff who cared for them.

People received care that responded to their needs. People were supported to remain independent and pursue individual hobbies and pursuits. People and relatives felt able to raise complaint or concerns with management, and regular forums were held for people to do so. The Registered Manager operated a robust complaints process that when required reviewed and responded to complaints appropriately.

Governance systems and updates in people`s care records continued to be an area that was under development, however the registered manager was able to demonstrate to us how they were addressing these issues. People were positive about the management team and told us that significant improvements had been made across the home by the management team and the provider.

Inspection areas



Updated 11 January 2017

The service was safe.

People were supported by enough staff to meet their needs in a timely manner.

People felt safe and staff were aware of how to identify and respond to any suspicion of abuse or harm to a person.

Risks to people’s health and well-being were identified and people felt they had choice and control over how these risks were managed.

People's medicines were managed safely and administered as the prescribed intended.



Updated 11 January 2017

The service was effective.

Staff felt supported by the management team, training had been provided where required and a development plan was in place for future staff development.

Staff were observed to seek people's consent for day to day tasks, and where people lacked capacity to make their own decisions staff acted in accordance with the Mental Capacity Act 2005.

People's nutritional needs were met. There were sufficient choices of appropriate foods and drinks for people.

People were supported by a range of healthcare professionals.



Updated 11 January 2017

The service was caring

People were treated with kindness and respect by staff who preserved their dignity when assisting them.

People and staff had formed strong positive relationships allowing staff to get to know each person's particular needs.

People were supported to access a range of advocacy services when required.



Updated 11 January 2017

The service was responsive.

People we spoke with told us they felt staff listened to them and their views about their care mattered.

Care was provided to people in a manner that met their individual needs and preferences.

People were supported to pursue interests and engage in social events and activities both in and out of the home.

People we spoke with were aware of how to raise any concerns they had.


Requires improvement

Updated 11 January 2017

The service was not consistently well led.

People's care records were not consistently completed when required.

Governance in the home had improved however the registered managers service improvement plan did not encapsulate all areas that required addressing.

People's views and opinions about the management of the home had been sought.

People and relatives felt the management team were open, honest and transparent.