Lilibet House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

This is the first assessment for this service. This key question has been rated good.

This meant people were safe and protected from avoidable harm.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service had a consistent approach to learning from incidents or feedback. Registered manager and house manager audits were completed and staff we spoke with were able to explain the process for reporting. Where incidents had happened and staff had completed incident forms, the management team had consistently reviewed these forms to identify and mitigate any potential ongoing risk to people and shared this learning quickly with staff to improve their knowledge and to ensure people’s ongoing safety. Lessons learned were discussed at staff meetings between the management team and staff.

Relatives knew who the registered manager was and felt able to raise concerns if they had any.

This meant the service had a positive culture of safety and learning from incidents.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service used a robust pre-admission tool, which allowed them to ensure they could meet peoples identified needs prior to them staying at Lilibet House. A staff member told us, “When a person is admitted into the home, we do a full body map, and if we find anything we report this. We ask people about their likes and dislikes. We get to know them. We report any findings to the seniors who add this information to the care plan.”

People and their relatives were involved in planning their care and support needs. One relative told us, “They know (person) inside out and are so nice to (person).”

People had documents in place such as About Me booklets which enabled all staff and external professionals to support them in their chosen way without the need of people having to communicate their wishes repeatedly. Additionally, people had communication passports in place, which described their preferred communication method. Where people were unable to communicate verbally these documents contained guidance on what was important to people and how they communicated and expressed themselves through body language, sounds and gestures. This meant external professionals and new staff could learn the persons preferred communication method and support them safely.

Contact was maintained with the local authority, social workers, GPs, district nurses, and other professionals when required.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately in most cases.

Staff were knowledgeable about safeguarding risks specific to individuals. People had a staff member who was assigned as their key worker. This meant staff were able to build trusting relationships with people. Staff we spoke with were knowledgeable about safeguarding risks and what this meant individually to people staying at the home. For example, staff were aware of people who were at a potentially higher risk of safeguarding concerns such as self-neglect or emotional abuse. Where concerns had been raised the management team had shared and reported concerns quickly and appropriately with the relevant agencies such as police and the local authority and investigations had taken place. However, the information had not been shared with CQC. This was an oversight and was immediately rectified during our assessment.

Relatives and people, we spoke with told us, “No safeguarding’s in all the time (persons) been there.” “I feel safe. It’s my life.”

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The provider understood the importance of involving people and those close to them in managing risk and completed Mental Capacity Act (MCA) assessments where needed. This helped ensure decisions made on behalf of people who lacked capacity were lawful and supported by appropriate advocacy.

Relatives we spoke with overwhelmingly felt that care plans and risk assessments were up to date, well understood by staff, and developed in partnership with families.

Most support plans and individual risk assessments identified key risks and provided guidance for staff. However, some health risks did not contain sufficient detail to ensure staff were aware of their responsibilities should the service user not be able to manage their own health condition.

The registered manager acknowledged the concerns raised during inspection and began reviewing the affected areas to implement improvements immediately.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, and facilities supported the delivery of safe care.

We observed windows on the ground floor that did not have window restrictors in place. Whilst the height of the windows was not a concern, they did open out onto the car park and onto a very busy road. The window restrictors on the upper windows were not secure and could be removed. We raised this during our assessment and replacement restrictors were sourced and replaced within the assessment period.

We observed 2 electric radiators in shower rooms that had no thermostatic control. These could become extremely hot and potentially lead to contact burns. However, the registered manager had these removed immediately. Consideration was also made to the other radiators which did have thermostatic valve controls. However, they were still able to reach a temperature of 55 degrees Celsius. The registered manager took action to reduce the temperature of the radiators to the recommended 43 degrees Celsius. These controls could only be accessed and amended by staff. We observed this change at our out of hours visit.

Personal Emergency Evacuation Plans (PEEP’s) records and the fire evacuation plan were all completed and up to date. These included information on the location of service users and what support was required to firstly understand what the alarm was and how they should be evacuated. Corridors were clear of any blockages, allowing people to follow easy to read escape routes. Staff had access to fire-fighting equipment.

All service users were risk assessed prior to each stay at Lilibet House for use of the stairs. This ensured that room allocation remained appropriate.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Our observations, along with a review of staffing rotas, showed there were enough staff on duty to support people safely. Staff were deployed effectively across the service; this ensured they were available to provide timely support when needed. Staff told us they felt confident that staffing levels were appropriate and enabled them to respond quickly to people’s immediate needs.

Staff were suitably trained for their roles, and we saw they used their training and skills effectively to meet people’s needs. Once staff had completed their initial training, there were clear processes in place to assess ongoing competency. Where any gaps were identified, managers arranged additional support or refresher training to further develop staff skills.

Staff told us they received regular one‑to‑one supervision with their line manager. These meetings allowed them to discuss their experiences, review their performance, and request further guidance or training. Staff spoke positively about the support they received and felt this helped them carry out their roles effectively.

However, safe recruitment procedures were not always consistently followed. We found examples where: not all previous employers had been contacted for references; interview notes were incomplete or missing.

The provider was aware of these concerns and had already introduced improvements to recruitment processes and documentation. Due to low staff turnover, these revised systems had not yet been tested fully across multiple new staff files.

All staff had an up‑to‑date Disclosure and Barring Service (DBS) check. These checks identify any criminal convictions or warnings that may affect a person’s suitability to work with vulnerable people. Staff identification documents had also been verified as original or checked for true likeness. This was recorded on a staff right to work document, contained in all files.

This meant staffing at the service was safe, and people were protected from avoidable harm.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

People and their relatives told us that the home was kept clean. People told us that staff wore personal protective equipment (PPE) as needed. Staff received training about infection prevention and control (IPC) and wore and disposed of PPE appropriately. Staff at Lilibet house carried out the cleaning during shifts. We saw evidence that all rooms were deep cleaned between respite stays. This included laundering of all pillows, duvets and mattress protectors. This ensured good standards of hygiene and cleanliness.

The local authority infection prevention and control team provided us with information that there had been no outbreaks of infection over the last 3 years.

Staff had received food hygiene training. They were able to explain what actions they took to reduce the risk of food borne infections. We saw the kitchen was managed in a hygienic way to ensure people were not exposed to the risk of food borne infections. The most recent check from the food standards agency, had rated the service 5, very good, on 28 April 2023.

However, we identified areas in each shower room that were difficult to clean due to peeling or mouldy sealant in shower trays or around sinks. We immediately brought this to the attention ofthe registered manager. We were provided with evidence within the week that these areas had been repaired.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

The provider ensured staff received regular competency checks for medicines administration. A comprehensive monthly audit identified examples of good practice and areas for development.

People received their medicines safely and when required. A relative told us “(persons) medication is always administered correctly and I've never had any concerns.”

Medicines were provided by the persons family for the duration of the respite stay. Staff shared examples of raising concerns with relevant professionals if families’ instructions did not match the corresponding prescribed dosages. No medicines were stored on site if the service did not have respite residents. There were no controlled medicines on site during our assessment.