Lilleybrook Care Home

Updated 1 May 2026

Date of assessment: 6 May 2026 to 21 May 2026. We visited the service on 6 and 8 May 2026. Lilleybrook Care Home is a 'care home'. People in care homes receive accommodation and nursing and/or personal care as a single package under 1 contractual agreement dependent on their registration with us. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Lilleybrook Care Home is registered to provide personal care to up to 62 people over 65 and/or living with a diagnosis of dementia. We carried out this assessment in response to information of concern regarding the management of risk. At the time of our inspection there were 61 people receiving support at the service. There was a registered manager in post at the time of the assessment.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. There were systems and processes in place to administer medicines safely however, they were not always effective in ensuring safe management of medicines.

We saw inconsistencies in records such as care plans and risk assessments, which required updating. Some care plans lacked key information regarding the management of risk, and we did not always see a clear record to demonstrate how decisions had been taken in relation to risk.

There was a governance structure in place to support the provider and management team to undertake their roles. However, the governance systems we saw at the time of assessment had not been consistently operated to effectively monitor the service and identify the shortfalls we saw in relation to care planning and medicines.

We received mixed feedback from people, relatives and professionals about whether there were always enough staff available to support people’s needs. We raised this with the provider who showed us how they had had calculated their staffing levels to ensure there were enough staff to meet people’s needs.

People were supported to make choices, maintain independence and engage in meaningful activities. Feedback about the improved activities programme was particularly positive, with people describing increased enjoyment, laughter and social engagement. Staff recruitment processes were safe. Infection prevention and control measures were effective, and the environment was well maintained and adapted to meet people’s needs.

This inspection found the provider to be in breach of legal regulations relating to safe care and treatment and good governance. In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.

The provider and registered manager were responsive to all issues raised during this assessment, and the leadership team put immediate measures in place to make improvements where they agreed there were shortfalls.

Updated 1 May 2026

We received mixed feedback from people and their relatives about the quality of their care. Whilst some relatives raised concerns, other relatives told us their loved ones received high quality care from knowledgeable staff. One relative said, “[Since my relative moved here], it has been absolutely perfect.”

Most people and relatives praised the improved activities schedule to keep people physically and mentally active. One person said, “They [activities team] come to me every day, they make me laugh. They did a show yesterday wearing sombreros and they came to my room and sang to me."

People also benefited from links with the local community and staff worked with specialist providers to deliver activities such as therapy animal visits. Staff also maintained links with a dementia choir in the community and received visits from a local charity reaching people with dementia through music and song. This provided meaningful opportunities for interaction and helped people remain connected to their community.

Some people could not directly tell us about their experience. We used a structured observation tool to assess whether they received good care. Our observations on day one of the assessment were not always positive and details have been shared in this report. However, the registered manager explained that staff had acted outside of their usual practice as they were being observed. The registered manager took immediate action in response to the concerns shared, and our observation on day two of our assessment was positive and showed people receiving good care.