Archived: Lillibet Court

Updated 6 August 2016

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 was an unannounced focused inspection of Lillibet Court which we undertook on 19 July 2016. The inspection was carried out to check that improvements to meet legal requirements planned by the provider after our comprehensive inspection on 12 May 2016 had been made. The inspection was undertaken by one inspector.

Before the inspection, we checked the information we held about the service and the provider, such as notifications. A notification is information about important events which the provider is required to send us by law.

In addition, we asked for feedback from the local authority who have a quality monitoring and commissioning role with the service.

During the inspection we focused on two of the five questions we ask about services: Is the service safe and is the service well led? This is because the service was not previously meeting legal requirements in relation to these two areas.

Because the areas requiring improvement were records based, we did not need to speak with people using the service about them on this occasion. We did however speak with the registered manager and a care member of staff.

We also looked at care records for one person, as well as other records relating to the running of the service, such as audits and meeting minutes; to corroborate our findings, and to check that the required improvements had been made.

Updated 6 August 2016

Lillibet Court comprises of 27 individual self-contained flats. The service provides support and / or personal care as required, for adults of all ages who may have a range of care needs, including dementia, mental health, learning disabilities, physical disabilities and sensory impairments.

There were 27 people living at the service on the day of this inspection.

The service is also registered to provide care and support to people in their own homes (off site), as part of an agreed care package. However, this was not happening at the time of this inspection.

We carried out an unannounced comprehensive inspection of this service on 12 May 2016, and found that four legal requirements had been breached. The provider sent us an action plan after the inspection, setting out what they would do to meet legal requirements and address these concerns. We undertook this focused inspection to check that they had followed their plan and to confirm that they now met the legal requirements.

This report only covers our findings in relation to these areas. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘Lillibet Court Limited’ on our website at www.cqc.org.uk.

During this inspection on 19 July 2016, we found that improvements had been made in all areas.

There was a registered manager in post. Like registered providers, registered managers are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

New systems had been introduced to improve the management and oversight of identified risks to people, such as weight loss or weight gain.

Steps had also been taken to ensure that legally required information, such as an incident involving the police, was reported to us, the Care Quality Commission (CQC), as required.

The arrangements for monitoring the quality of service provided had also been strengthened; to mitigate identified risks to people and ensure their health and wellbeing.

Although we found that the service was no longer in breach of legal requirements, we have not changed the overall rating for the service on this occasion, because to do this this would require consistent good practice over a sustained period of time. We therefore plan to check these areas again during our next planned comprehensive inspection.