Lilleybrook Care Home

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 assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. Whilst we saw no evidence of impact, there was an increased risk that people could be harmed.

The service was in breach of legal regulations in relation to people’s safe care and treatment and good governance.

This service scored 56 (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 had a proactive and positive culture of safety, and staff listened to concerns about safety and investigated and reported safety events. Whilst lessons were learnt to identify and embed good practice, more time was needed for governance systems in this area to be successfully embedded.

Incidents were reported and investigations were carried out. There were some positive learning initiatives, and ‘you said we did’ documents were completed to learn and develop from feedback. Despite this, governance and audit systems had not identified or taken sufficient action to resolve all the issues we found during this assessment. We raised this with the provider and registered manager who took immediate action to address the areas of improvement. The registered manager told us that learning from the assessment was discussed with staff and embedded into the service improvement plan.

Some relatives told us they were not confident that the worries or concerns they raised with staff were escalated promptly and followed up by managers. In contrast, other relatives told us they felt assured that any feedback they raised would be acted upon. One relative said, “[I have] never needed to complain and any requests [I’ve] made have been dealt with.”

We received mixed feedback about whether the provider worked 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.

We received mixed feedback from relatives and professionals about the effectiveness of partnership working. Whilst some relatives spoke highly of the way in which staff managed and monitored people, some relatives raised concerns about whether staff reliably escalated concerns if their relative was unwell. We received some positive feedback from professionals who stated that staff consistently work well with them to establish and maintain safe systems of care, whilst another professional shared a different experience and raised concerns about the consistency of partnership working.

The registered manager told us that staff supported people safely and responded appropriately when people’s needs changed. However, there was not always a clear record to assure us that information had been clearly updated in response to advice from health professionals. For example, after a person had been discharged from hospital we saw a lack of consistency in the care record about how often aspects of their care needed monitoring and why certain decisions had been made relating to the management of risk. Whilst the registered manager was able to discuss this with us verbally, and gather information across different areas of the care notes to justify decisions made in relation to risk, the absence of a clear record placed the person at risk of not receiving care and treatment as agreed with healthcare professionals. We shared this information with the registered manager who took immediate action to review and update the record.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

There was a safeguarding file in place which documented the management of safeguarding concerns. We saw that information had been shared with relevant system partners such as the local authority and the Care Quality Commission in a timely manner.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found the provider had applied to the local authority for DoLS authorisations where appropriate. The registered manager had a record of all DoLS applications that had been made, including details of any conditions to the authorisations.

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

Risk assessments and care plans had not been consistently updated to reflect people’s changing needs. One person’s care plan contained contradictory information relating to their falls risk as they were described as both a moderate and high falls risk in different sections of the care plan. The provider told us this inconsistency was a result of an incomplete records update due to a recent increase in the person’s needs, and not a failure to assess or monitor falls risk. Another person’s care plan identified a health risk which required regular and consistent monitoring. Whilst the registered manager told us they were confident that staff knew how to recognise and act when there were signs of deterioration, there was not a clear record to show how this was being safely and consistently monitored. We raised this with the provider who told us they have now consolidated the relevant records so that the monitoring approach and escalation triggers are clearly documented in a single place.

We received mixed feedback from relatives around the management of risk. Some relatives told us they were not assured that staff fully understood the complexity of their relative’s needs, whilst others told us they were happy with the management of risk. One relative said, “Within the first couple of weeks I knew that the nurses [were] brilliant. [My relative has complex health needs] and we had lots of concerns about [how staff would manage this]. Here I have not had to ask once [and staff manage these risks associated with my relatives care]."

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The provider completed various health and safety checks to make sure the premises, and any equipment was safe. The provider had a legionella risk assessment and water samples were regularly tested to ensure they were safe. Equipment was serviced regularly and staff completed regular checks of the environment to identify any shortfalls.

There were effective fire safety procedures in place. The signage, the decoration and other adaptations to the premises helped to meet people’s needs and keep them safe.

We received mixed feedback about whether the provider always make sure there were enough staff. We also received mixed feedback about whether staff always worked together well to provide care that met people’s individual needs.

We reviewed dependency tools which routinely calculated the needs of each person and the overall number of staff needed in the home at any one time. Whilst we saw that staff had been allocated in accordance with the levels indicated in the dependency tool, we received mixed feedback about staffing levels in the home from professionals, people and relatives. One relative told us that they believed there were enough staff and said, “We have always been able to get hold of staff, when needed”. This was reflective of the views of other people and professionals we spoke with. In contrast, some relatives, people and professionals raised concerns about the staffing levels. Some relatives told us there were delays to care and treatment as there were not always staff available, and some people raised concerns that there was not always enough staff to cover when it was needed.

Staff told us they received effective training to deliver care safely and competently, and we saw that there was a training matrix in place to monitor the training which staff received.

Staff were recruited safely. All required checks were made before new staff began working at the home.
 

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.

The home was clean and well maintained, and arrangements were in place to reduce the risk of infection. We observed bedrooms, communal areas and equipment were kept clean, and any issues identified were addressed promptly to help keep people safe.

People and their relatives spoke positively about the cleanliness of the home. One relative told us the home was, “Always clean”. Another relative told us, “The laundry is absolutely spot on. The [person] they have is absolutely brilliant. [They] always speak and always help. If I can’t find something then [they] find it within minutes.”

Staff followed expected infection prevention and control practices and had access to appropriate personal protective equipment (PPE), and an up-to-date infection prevention control policy. Observations and records showed these practices were followed in day-to-day care, which helped reduce the risk of infection transmission.

Environmental arrangements supported safe practice. The registered manager had direct oversight of the housekeeping team to ensure that rooms and communal areas were kept clean, and equipment used in people’s care was checked and maintained to reduce the risk of contamination.
 

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

There was a system in place to order medicines through the residents' GP practice ontime, and these were supplied by a nominated pharmacy. Medicines, includingcontrolled drugs, were stored safely and temperature checks of storage areas werecarried out.

We identified concerns with how medicines were managed and administered.

Records used to guide staff, such as medication administration records (MAR) chartsand care plans, were not always accurate and sometimes contained conflictinginformation. This put people at risk of receiving medicines not prescribed as intended.Some handwritten medicine records were incomplete, meaning staff could not always
confirm when medicines had been given.

Medicine stock balances did not always correspond with recorded quantities, andsome entries were inaccurate or incomplete. This meant we could not be assured thatmedicines were consistently administered and documented accurately.

Staff did not always follow the correct procedures when administering medicines. Forexample, we found concerns with how medicines were given via percutaneousendoscopic gastrostomy (PEG) tubes. Medicines were not always prepared correctly,and they were sometimes given together instead of separately. This practice increasesthe risk of the tube becoming blocked and could affect how well the medicines worked.The provider has since reviewed their practice and taken action to ensure medicinesadministered via PEG tubes are given in line with best practice guidance.

Allergy information was not always clearly recorded or aligned with prescribedmedicines. In some cases, medicines had been prescribed despite recorded allergieswithout a clear explanation, placing people at potential risk of harm.

Monitoring of people’s health was not always clearly evidenced through records. At thetime of our assessment, the monitoring being undertaken did not always align with themonitoring requirements set out in people's care plans.

Care plans did not always provide enough information to support safe administration.Guidance on monitoring certain medicines and when to seek medical advice wassometimes missing. For example, care plans for long-term conditions and behaviouralneeds were sometimes missing or lacked sufficient detail.

A risk assessment was not completed when one person did not receive theirprescribed medicines while away from the service.

Instructions for ‘as required’ (PRN) medicines were not always clear, which created arisk of under- or over-administration.