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 inadequate. At this inspection, the rating remains inadequate. This meant people were not safe and were at risk of avoidable harm.

The service remains in breach of legal regulations related to safeguarding, safe care and treatment and staffing. Safeguarding concerns were not always reported. Incidents were not always well documented or managed. Care plans did not always contain enough information on managing risks. Medicines were not always managed safely. Some staff did not have all the training they needed to support people safely. Staff competence to support people was not being checked effectively 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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Since our last inspection the provider put measures in place to ensure staff reported incidents appropriately so lessons could be learned. These included daily written handovers and monthly manager reviews of daily records to capture any incidents. However, these had not been effective, and we found numerous occasions where lessons could have been learned from incidents that had been reviewed but were not. These included for example, when people had become upset with one another or when unexplained bruises were found on people. This reduced the opportunity for lessons to be learned and placed people at increased risk of harm. The provider reviewed these incidents again during our inspection, however we could not be assured this would have happened were it not for our review of incident records.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

People’s records, such as those relating to food and fluid intake and pressure area care were not being effectively reviewed to see if they needed support in different ways to meet their individual needs or to transition to another service. Staff supporting people to appointments did not always have the necessary information or knowledge to help professionals understand and support people. For example, staff were unaware where to find information about people’s medicines or the way they wanted to be supported during appointments.

However, people did go and see other services or have health professionals visit them when they needed support. One relative said, ‘‘[Staff] have always been good at noticing when [family member] may need help from [professional] and organise this quickly.’’

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

Since our last inspection daily records and identified incidents were being reviewed by the management team. However, we still found several times where the provider had failed to identify and report safeguarding concerns to the Local Authority safeguarding team. Failing to recognise potential safeguarding concerns placed people at increased risk of harm. Staff recording and reporting of incidents remained variable, meaning there was an increased risk that potential safeguarding concerns were not being reported so they could be thoroughly investigated. A relative told us, ‘‘I so not understand how [family member] has [incident] happening to them as they spend their time in their room. I do not always get told what is happening.’’

Despite our findings, people and their relatives told us staff supported them/ their family member safely. One person said, ‘‘The staff make me feel safe.’’ A relative told us, ‘‘I honestly do not think [family member] would still be here if it was not for [staff’s] support and care.’’

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Since our last inspection, the provider and management team reviewed all care plans and risk assessments to ensure they contained up to date and correct information about how to support people. They had signed this in an action plan to state this had been completed. However, some care plans and risk assessments remained unclear and inconsistent. For example, they recorded different textures of food people needed to eat differently throughout the care plan, fluctuated between how many staff members people needed to be supported safely and incorrectly recorded whether people were able to mobilise independently or not. Care plans and risk assessments for specific conditions such as epilepsy, diabetes or living with dementia were generic and did not give detailed advice about how to support people with these needs. People’s daily records continued to not be completed in detail, making it harder to identify if a person may need more help with some areas of their support. It was unclear if or how people and their relatives had been supported to feedback and be a part of discussions about care plans and risk assessments. One relative told us, ‘‘I have never seen or been asked what I feel about [family members care plan] since it was first put in place.’’

However, some people’s care plans and risk assessments were more detailed and gave good guidance to staff about how to support people. Relatives told us staff supported their family member to mitigate risks as far as possible. One relative told us, ‘‘[Staff] have adapted well to [family member’s] changing needs and support them safely.’’

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

At our last inspection, we identified several concerns in relation to fire safety. The provider had started to address these concerns and had made some progress. However, several areas of fire safety such as unsafe gaps in fire doors and a padlock being used to lock a fire escape had not been addressed. This continued to put people at risk of harm. The provider rectified these issues during our inspection.

Other areas of the environment and people’s equipment was kept safe and staff completed checks to make sure this was the case. One person said, ‘‘[Staff] keep things beautiful here.’’

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

At our last inspection, staff did not have the training or competency to support people safely in areas such as moving and handling, administering medicines or person-centred care. Following this, the provider completed competencies for all staff in all areas of care provision over a short period of time. Several actions from these competencies were recorded such as staff needing more specific training or needing to read care plans in more detail. However, these had not been completed. Other than these competencies, no other support had been given to staff to help them understand their training and help make sure it had been effective. We were not assured the actions taken by the provider had been effective in supporting and making sure staff were competent in their job roles. This put people at risk of being supported by staff who were not competent to support them with all their needs.

We received conflicting and inconsistent information from the provider and management team about staff training. We were shown several training records, some of which indicated staff were not trained in all areas of their job roles such as fire safety, supporting people living with epilepsy or supporting people living with dementia. We were later shown records indicating staff training was fully completed for all staff. The manager was unsure where the correct training records were kept. In one case, the manager knew a member of staff working in the kitchen did not have the training they needed to support people safely. This included how to support people with specific dietary needs. Staff knowledge about their training was variable and staff told us training was not discussed with them to help make sure they understood what they had learned. Being unsure and unclear whether staff had training or monitoring how effective this had been, placed people at increased risk of harm.

We observed there to be enough staff to support people safely with their support needs such as personal care. However, staff told us they were incredibly busy due to the complex support needs of people using the service, meaning other than essential support such as personal care or making sure people had enough to eat and drink, they did not have time to spend time with people. We observed at some times of day staff deployment meant people were not engaged with in a meaningful way for extended periods of time. One person said, ‘‘I don’t really see [staff] much, but they come if I need them.’’

However, feedback from relatives was there were enough staff to meet people’s needs. One relative said, ‘‘Whenever I visit there are always [staff] around and I know [family member] has everything they need to be happy.’’

The provider’s recruitment checks for new staff were not always safe or in line with legislation. Full employment histories for new staff had not been obtained by the provider before staff started working for them. Other checks were completed safely in line with legislation.

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.

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, ‘‘The service is very clean, and staff do a good job.’’ A relative said, ‘‘The provider makes sure there is always a staff member at all times of day to clean the service, and this has made a big difference.’’

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

There had been some improvements in the way staff administered medicines to people since our last inspection. However, we found multiple other areas of medicines practice that were unsafe. Medicines, including those that needed to be disposed of were not being stored safely. Medicines such as morphine were being kept ready for administration when they were out of date. The provider’s stock checks of medicines differed from the actual count of medicines indicating people were not being supported with the right number of medicines. People who were prescribed ‘as and when’ required (PRN) medicines, did not always have guidelines in place, or have detailed guidelines in place so staff knew when to administer these medicines. Where, medicines errors were identified, there was limited evidence these were shared with the staff team to help learn lessons and drive improvements. The provider started implementing improvements based on our feedback, however we could not be assured this would have happened without our direct intervention and feedback.