- Care home
Lillibet House
Assessment report published 13 November 2025
Contents
Ratings
Our view of the service
Date of assessment: 31 July 2025 to 05 September 2025
Lillibet House is a care home supporting people who may be living with dementia, mental health support needs, or a physical disability. The service provides accommodation for people who need personal care and nursing care. The service can support up to 30 people and 27 people were living at the service at the time of our inspection.
At our last inspection, the service was in breach of a regulation of the Health and Social Care Act (2014) in relation to safe care and treatment. At this inspection the service is still in breach of this regulation, and we also found breaches in other regulations in relation to safeguarding people from abuse, staffing, person centred care, dignity and respect, good governance and the reporting of notifications to the Care Quality Commission (CQC). The service has changed from requires improvement to inadequate at this inspection.
Systems were not in place to identify potential safeguarding concerns and take action to safeguard people. People’s risk assessments and care plans were not always up to date with their current support needs and in some cases, people did not have care plans in place for all their support needs. People’s daily records were not being monitored to make sure support was being given to them in line with their identified needs. Staff did not have the training they needed to support people and were not having their competency to support people safely checked regularly. The service was not safe in relation to fire safety. People were not always being supported safely with their medicines. People were not being supported in line with best practice and staff did not have the knowledge to support people with specific support needs. It was not clear how staff were supporting people to live healthy lives. In some cases, people were not being supported in line with Mental Capacity Act (MCA). People were not always treated with kindness, compassion, dignity and respect and it was not clear how people’s individual preferences were being considered when they were supported. People were not always receiving person centred care, often going long periods of time without meaningful engagement. Care plans did not always cover how people wanted to be supported, and people were not being asked for feedback about the service in meaningful ways. Staff did not all feel well supported working at the service. Governance systems in place at the service were not effective in identifying and driving improvements.
However, some aspects of people’s care plans and risk assessments were more detailed, and person centred. The service was clean, and staff followed good Infection Prevention Control (IPC) measures. Staff contacted health professionals and worked well with them when necessary. Mental capacity assessments in place for people were detailed. We observed some kind and caring interactions from staff when they supported people. People and relatives were positive about their support. The provider and registered manager were responsive to some of our feedback and told us they would start working on improvements.
In instances where CQC has decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/or appeals have been concluded.
This service has been placed into special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.
People's experience of this service
People were not always being supported to have good experiences at the service. Staff did not always treat people with person centred care, dignity and respect and people were not always kept safe as safeguarding concerns were not being identified and dealt with in a timely and appropriate manner. Despite CQC finding that people’s care had significant shortfalls in relation to the standards we expect, overall, most people and relatives were satisfied with the care people were receiving.
People told us they were happy living at the service. We observed people to be happy and relaxed whilst being supported by the staff team. Relatives described staff as kind and friendly and felt they knew their family member well. One person said, ‘‘My life is happy here and I am happy with my life now.’’ A relative told us, ‘‘I am happy with the service, and the staff are all caring.’’