Lillington 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.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 69 (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.

There was a culture of curiosity and learning to ensure standards were maintained and best practice implemented within the home. One staff member told us, “If something is raised or happens, we get together, discuss what happened and how we can improve. By sharing knowledge and skills, it increases confidence and benefits the patients.”

The provider had processes to collate queries or concerns about people’s care which were then shared and discussed at weekly multi-disciplinary meetings. Responses were fed back to the staff team to inform improvement and promote the delivery of consistent and safe care.

Accidents and incidents were recorded and reported. The provider and registered manager had regular oversight of accidents and incidents to identify any trends and areas for learning and development.An external healthcare professional told us, “Management takes all concerns, advice and guidance very seriously and they are very proactive when there are safety issues.”

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.

Staff worked with external healthcare professionals to ensure people had a safe transition to Lillington House. Pre-admission assessments were always completed face to face to ensure people’s clinical needs could be met and planned outcomes could be achieved. One staff member explained, “When we receive a referral from the ICB (Integrated Care Board), if it indicates the placement would be appropriate, a nurse manager and therapy manager go out to assess. We take time to meet the person, to look at all the notes and learn about the person’s past history and current circumstances. Then we write a bespoke plan which we share with the ICB.”

Effective information sharing ensured safe systems of working were in place and established prior to a person transitioning to Lillington House. One staff member explained, "We are always thoroughly informed when someone is coming in and what equipment they need." One family member told us the transfer of their family member from hospital to the home had been managed well.

When people were admitted to hospital, a member of staff with the appropriate skills accompanied them. For example, people who required respiratory support were accompanied by a member of clinical staff. Processes were in place to ensure other healthcare professionals had the information they needed to understand people’s risks, support needs and preferences for future care.

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.

People felt safe living at Lillington House and with the staff who provided their care. One person told us, “It is the staff and the other residents that make me feel safe. If I didn’t, I would speak to [name of staff member].” Another person commented, “I am very safe, the place itself makes me feel safe. If I had a problem I would speak to [name of staff member].” A relative told us, “[Name] is quite safe. I don’t feel nervous about them being looked after here.”

Staff valued their role in caring for people with extra vulnerabilities due to their complex medical conditions. They told us they would escalate any concerns to keep people safe. One staff member told us if appropriate action was not taken initially, “I would take it further to [clinical manager]. She would do something about it, I know she would, she wouldn’t leave it." Another staff member told us, “You have to investigate these things and if you have to take action to safeguard people, then so be it. They (managers) are very process driven when it comes to investigations and disciplinaries. They take things like that very seriously.”

The provider’s safeguarding processes ensured concerns were investigated and referred to the local authority safeguarding team.

When receiving care and treatment, people can only be deprived of their liberty with the appropriate legal authority. In care homes, this can be done through a procedure called The Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act (MCA) 2005. We checked how the provider managed DoLS within the home. When someone was identified as potentially being deprived of their liberty, applications had been made to the authorising body as required.

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.

Risks to people's health and safety had been identified and assessed. Clear guidance was in place to direct staff on how to support people in a safe way. Risk management was based on people's individual abilities and reviewed regularly or in response to incidents or changes in people's health.

Some people had complex and unpredictable clinical needs. Deterioration and clinical risks were anticipated, and guidance was in place to reduce the potential for harm.

Managers and staff understood their responsibility to ensure people had information and understanding about risks associated with their medical conditions and any planned clinical interventions. People’s right to take decisions with risk was respected and strategies implemented to mitigate those risks whilst adding meaning to the lives of people where possible. The clinical manager explained, “We would use all the multi-disciplinary team to support effective communication and support the individual to make the most appropriate decision. You don’t want an environment people live in that is top heavy medicalised and you want it to be person centred with the acknowledgement people can make decisions with risk." One staff member told us, “We have to respect patient’s wishes. If a patient has capacity and wants to eat but this places them at risk of choking, we have to respect that. We talk through all the risk and explain it in detail. We try to look for alternatives and make suggestions but ultimately it is the person’s choice.”

The provider did not always detect and control potential risks in the care environment. However, they made sure equipment, facilities and technology supported the delivery of safe care.

At the start of the inspection Personal Emergency Evacuation Plans (PEEPs) could not be located by reception staff or members of the management team. This meant information staff and the emergency services needed to keep people safe in the event of a fire or other emergency was not easily accessible. High-priority actions identified in the fire safety risk assessment completed by an external contractor in January 2026 had not been addressed within an appropriate timescale. The registered manager immediately responded to our feedback to ensure PEEPs were accessible and the high priority actions were addressed.

The provider carried out regular checks on the environment and equipment to ensure they were safe and ready for use.

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.

People and their relatives had no concerns about the knowledge and competency of the staff team. They told us staff were visible and available when they needed them. One person told us, “I have a call bell and when I use it, they (staff) are not far away.” Another person explained, “There are plenty of staff, no problems there. I have 1 to 1s as well.” Comments from relatives included: “From what I see, the staffing levels seem okay”, “I always see enough staff, I just pop my head out and they come” and “I have no complaints about staff, they are quite competent in what they do.”

One relative told us their family member had said agency care staff did not always make them feel as comfortable when providing personal care as the permanent staff, who knew them well. The registered manager acknowledged that agency usage had increased, but new permanent care staff were due to start employment after a recruitment campaign. The clinical manager confirmed they did not use agency nursing staff due to the complexity of people’s medical interventions. A visiting healthcare professional described staff as experienced and competent.

Staff levels were based on a breakdown of people’s individual clinical and care needs. Where a change in need was identified, staffing levels were reviewed to ensure the provision of safe care. For example, staffing levels had recently been increased in the afternoon in response to staff feedback.

Staff told us there were generally enough staff to provide people’s planned care but acknowledged it could be very busy due to the unpredictability of people’s complex conditions. One staff member told us, “Sometimes when a new resident comes in it is a bit difficult because it takes longer to get to know their routine and everything." Another staff member commented, “It is just continuous, so an extra pair of hands to assist with showers and so forth would be nice.”

Staff were recruited safely in line with the provider’s procedures and best practice guidance.

The provider assessed and managed the risk of infection. However, some practices needed to be improved to reduce the risks of any infection spreading.

People and their relatives raised no concerns about cleanliness standards in the home. Comments included: “There are no issues with cleanliness here”, “I have no cleanliness concerns at all” and “I am quite happy with the cleanliness in [Name’s] room.”

The provider had a comprehensive and up to date infection control policy and procedure. However, some practices did not promote good infection prevention and control, and some areas of the home required maintenance which made them difficult to clean.

All staff received infection prevention and control training and were seen to use and dispose of personal protective equipment appropriately. However, some staff wore items of jewellery which conflicted with the requirements of the provider’s dress code policy.

The clinical manager assured us immediate action would be taken to address the shortfalls identified.

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.

People and their relatives expressed no concerns about the availability and management of their medicines. One person told us, “I have pain all the time, if I need pain relief they give it to me.” A relative confirmed, “There are no concerns about medication management at all.”

Staff followed best practice guidance in their management of people’s medicines. Storage arrangements for medicines were well managed. This included stock control and ensuring medicines were stored in accordance with manufacturer’s guidance.

Where people were prescribed medicines to be given as and when required, there was guidance in place to ensure they were given when needed. Medicines which required extra checks were managed in accordance with legislative requirements.

Our observations confirmed staff followed best practice principles when administering people’s medicines.