Archived: Lillibet Manor

Updated 8 April 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 22 February 2017 and was unannounced. The inspection was undertaken by a team of two inspectors and an expert-by-experience. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service. The expert by experience used for this inspection had experience of a family member using this type of service.

Prior to this inspection we reviewed all the information we held about the service, including data about safeguarding and statutory notifications. Statutory notifications are information about important events which the provider is required to send us by law. We spoke with the local authority to gain their feedback as to the care that people received.

During our inspection, we observed how the staff interacted with the people who used the service, how people were supported during meal times and also during individual tasks and activities.

We spoke with four people living at the service and two relatives. In addition we spoke with the registered manager, the deputy manager, four care staff, and a member of catering staff. We also spoke with a consultant who had been bought in to the service to work on making improvements following the last inspection.

We looked at six people's care records to see if they were up to date and reflected their care needs. We also looked at other records relating to the management of the service, including staff recruitment, medication charts and quality audit records.

Updated 8 April 2017

Lillibet Manor is comprised of 34 single occupancy studio apartments within one converted building. The service provides an Assured Shorthold Tenancy provision and a choice of assisted living support options, or full residential care with accommodation and personal care, for adults of all ages who may have a range of needs. These include mental health, learning disabilities, physical disabilities, sensory impairments and dementia.

There were 23 people using the service at the time of this inspection, 12 of whom received a full residential care service whilst the remaining people had assisted living packages in place. The majority of the people receiving an assisted living package did not receive personal care, as regulated by us, the Care Quality Commission (CQC). Therefore information relating to them was not included in this report.

We originally carried out an unannounced comprehensive inspection of this service on 27 July 2016, and found that eight legal regulations had been breached.

The arrangements to manage and mitigate identified risks to people living at the service, were inadequate, and meant that people were being exposed to unnecessary risks. This was a breach of Regulation 12 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

There were insufficient numbers of suitably qualified, competent, skilled and experienced staff to meet people's needs. This was a breach of Regulation 18 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

Recruitment procedures were not sufficiently robust enough to ensure new staff were safe to work at the service. This was a breach of Regulation 19 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

Care and support was not always provided with the consent of people using the service. This was a breach of Regulation 11 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

The registered person had not taken steps to meet people's nutritional and hydration needs, which was a breach of regulation 14 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The registered person had failed to ensure that people consistently received care and support that met their individual preferences. This was a breach of Regulation 9 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

The registered person had failed to operate systems to ensure records were managed safely and effectively. Systems were inadequate in terms of assessing, monitoring and improving the quality and safety of the services provided. This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We found that some statutory notifications were not being submitted to CQC as required. This was a breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009.

Following this comprehensive inspection, we gave this location an overall rating of 'inadequate', and placed them into special measures.

We then carried out a focused inspection on 1 September 2016, to check progress with the proposed improvements in three of the most urgent areas requiring improvement; safe care and risk management, staff training and skill mix and quality assurance and governance systems. Although we found that improvements had been made during this inspection, it was clear that more time was needed to fully implement and embed the changes being introduced by the manager. At this time the service still remained in special measures.

The provider had submitted an action plan to tell us how they would meet these regulations and the timescale they intended to have met them by. We carried out this inspection on 22 February 2017, to see if the provider had made the necessary improvements to meet these breaches of regulations, and to see whether or not they should remain in special measures. We found that the provider had implemented systems to meet these regulations and, as such, the service is no longer in special measures.

During this inspection, we found that people felt safe at the service and were cared for by staff who were trained in safeguarding principles. Staff were knowledgeable about abuse and were prepared to raise any concerns they had. There were systems in place to assess and manage risks, and risk assessments were updated on a regular basis, to ensure they were accurate. The registered manager and consultant acknowledged that there was still further room for improvement in this area to ensure that they systems in place were fully robust. Staffing levels had improved and the provider had carried out recruitment to improve continuity of care. Systems for the administration of medication had been improved to ensure that this could be done safely; although we found that the electronic system in place could be utilised more effectively to ensure that stock levels of medication reconciled with what was in the service.

Staff training had improved and we saw that staff members now received regular training and refresher sessions, to ensure that their skills were up-to-date. Staff also received support from the registered manager, including regular supervision and appraisal meetings. People's consent to their care was sought, and systems for the implementation of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards had been developed. People had access to sufficient food and drink and were supported to see healthcare professionals when necessary.

Staff treated people with kindness and compassion and promoted their privacy and dignity. They spent time engaging with people in conversation and exchanging jokes. People were provided with information about their care, and there were plans in place to improve the recording of people's involvement in their care.

People's care plans were reviewed regularly, to ensure they were an accurate reflection of people's needs and wishes. The provider was in the early stages of using a new electronic care planning system, which would ensure that people were able to confirm their involvement in the care planning process. The activities programme was enjoyed by people, who were able to participate in a range of activities and there were plans to extend this father in the future. Policies and procedures for feedback from people and their family members were in place, and the registered manager sought out people's views to help develop the service provided.

There was clear leadership at the service. Staff and people were aware of who the registered manager was and were positive about the impact that they had at the service. The registered manager was aware of the requirement to send notifications to the CQC, and had done so where necessary. They had also implemented a number of checks and audits to ensure there were more effective quality assurance systems at the service.

At the last comprehensive inspection this provider was placed into special measures by CQC. Although we identified a number of areas during this inspection that still required improvement, we were satisfied with the progress that had been made and determined that the provider was no longer in breach of the Regulations of the Health and Social Care Act 2008 (regulated activities) Regulations 2014 (Part 3) and the Care Quality Commission (Registration) Regulations 2009. The overall rating for this service is 'Requires Improvement'. This means that the service no longer requires to be in 'Special measures'.