Lillibet 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 inspection we rated this key question requires improvement. At this inspection the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulations related to safeguarding, safe care and treatment and staffing. Safeguarding concerns were not always identified and reported. Incidents were not always well documented or managed. Care plans did not always contain enough information on managing risks and in some cases were not in place for people’s known support needs. Medicines were not always managed safely. The service was not safe from a fire safety perspective. Staff did not have all the training they needed to support people safely. Staff competency to support people was not being checked to make sure they could support people safely.

This service scored 38 (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 did not always have a proactive and positive culture of safety based on openness and honesty. They did not always identify concerns about safety and did not investigate or report safety events.

Staff were not reporting incidents, such as people showing they were unhappy or people refusing personal care to the management team. Whilst staff did sometimes record these events in people’s care records or on daily handovers, these records were not being monitored effectively to pick up on these events. This meant the management team could not investigate and report all safety events. This placed people at increased risk of harm.

Despite our findings people and relatives told us learning happened at the service. One relative said, ‘‘[Staff] will change how they do things if things are not working.’’

The provider did not always maintain safe systems of care to manage risks that people could experience or be exposed to. Safeguarding concerns were not always identified, and care plans did not always reflect people’s needs. When people started living at the service, there was limited evidence to show how their needs had been considered and the impact their support needs may have on people already living at the service. People’s records were not being effectively reviewed to see if they needed to be supported and transitioned to another service.

However, staff did notice when people needed support from other services and supported them to access these services when needed. One person said, ‘‘I have lots of treatment here and staff help me to my appointments.’’

People were not always protected from abuse and improper treatment. The provider had failed to identify and report all safeguarding concerns to the Local Authority safeguarding team. Incidents and accidents were not always being identified and dealt with in a timely manner. Failing to recognise potential safeguarding concerns placed people at increased risk of harm. Staff were not all aware of how to report safeguarding concerns to external partners such as the local authority safeguarding team or CQC.

Despite our findings, people and their relatives told us staff supported them/their family member safely. One person said, ‘‘I feel safe with all the carers, and I always have someone with me which makes me feel safe.’’

People’s risk assessments and care plans were not always detailed in areas such as how to support a person to feel better when they felt upset or how to support a person who was at risk of social isolation. Care plans and risk assessments were missing for some people living with specific support needs such as dementia or health conditions. Some care plans and risk assessments were unclear and inconsistent. For example, they recorded different textures of food people needed to eat differently throughout the care plan or fluctuated between how many staff members people needed to be supported safely. People’s daily records were sometimes not completed in detail, making it harder to identify if a person may need more help with some areas of their support.

However, other risk assessments and support plans were detailed and gave guidance to staff about how to mitigate risks as far as possible. People and relatives told us risks were managed at the service. One relative told us, ‘‘[Family member] is not always the easiest person to support but the staff manage the risks well and this means they are safe.’’

The provider failed to detect and manage all potential risks in the care environment. There were issues in relation to fire safety at the service which had not been identified by the provider. For example, a door in the kitchen area was being propped open and did not close securely which would be a concern in the event of a fire. Several fire doors were not in line with fire regulations in relation to gaps between the door and the door frame which limits the spread of fire. A fire risk assessment completed for the service had identified some other concerns, however these had not been identified by checks in place at the service. This put people at risk of harm if there was a fire at the service.

Other areas of the service were safe, and staff completed checks to help make sure this was the case. One person said, ‘‘The building is safe and secure, and I like it.’’ A relative told us, ‘‘I think the building is a little dated, but it has been well looked after.’’

The provider did not make sure staff were always trained or competent. A large number of the staff team had not recently completed training in areas essential to their job roles and supporting people. For example, many the staff team did not have training in areas such as supporting people living with dementia, safeguarding, moving and handling, epilepsy awareness, specific health conditions or the MCA. Staff were not having their competency to support people checked to make sure they could safely support people. We observed staff supporting people with their moving and handling needs such as using a hoist and this was not always safe. These staff had not had their competency in moving and handling checked recently. This put people at risk of being supported by staff who were not trained or competent to support them.

There were enough staff to support people safely. However, at some times of day staffing levels and staff deployment meant people were not engaged with in a meaningful way for extended periods of time. One person said, ‘‘It can be a little lonely here and I spend quite a bit of time by myself.’’

However, people and relatives told us there were enough staff to meet their needs. One person said, ‘‘I can always find someone when I need something.’’ A relative told us, ‘‘When I visit, I always see plenty of staff about.’’ Staff were also recruited safely in line with legislation.

The provider assessed and managed the risk of infection. Staff were trained in IPC and told us they had the necessary equipment to keep the service clean. We observed the service to be visibly clean. Staff whose role was to keep the service clean took pride in their work and knew how important it was for people’s home to be kept clean. Audits and checks were in place to monitor the cleanliness of the service and the effectiveness of the IPC measures in place. A person told us, ‘‘I used to like to clean my own room, but the staff help me now as I find this hard. They keep it nice and clean for me.’’

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. We observed staff administering medicines and noted several occasions where this was unsafe. For example, a staff member was observed to rub people’s throats, so they swallowed their medicine and administer medicines covertly when this was not in the persons best interests. We also observed staff signing to say all medicines had been administered to people when this had not been the case. We observed, and records showed that medicines were not being administered to people in a timely manner in line with prescriber’s instructions. Whilst action was taken by the provider when we raised these concerns, they had not been picked up by the providers own processes.

People had protocols in place for ‘as and when required’ (PRN) medicines. Audits took place of stocks of medicine to help make sure medicines were being administered safely. One person said, ‘‘I take lots of tablets and trust the staff to sort these out for me.’’