Archived: Lillibet Court

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.

Lillibet Court Limited is comprised of 27 single occupancy studio apartments within one converted building. The service provides a choice of sheltered accommodation or accommodation with personal care and support, for adults of all ages who may have a range of needs. These include mental health, learning disabilities, physical disabilities, sensory impairments and dementia.

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

There were 27 people using the service at the time of this inspection.

A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations.

Staff understood how to protect people from avoidable harm and abuse. However, improvements were needed to review safeguarding concerns; to identify potential patterns and to take any necessary actions to minimise the risk of a reoccurrence.

Risks were managed so that people’s freedom, choice and control were not restricted more than necessary. Improvements were needed however, to ensure individual risks associated with people's care were managed appropriately.

There were sufficient numbers of suitable staff to meet people’s day to day needs, but improvements were needed to meet people’s holistic needs as well as maintain a safe, hygienic environment.

The provider carried out robust checks on new staff to make sure they were suitable to work at the service however, not all legally required checks were in place.

People were supported to access relevant healthcare services. Although improvements were required to ensure people had access to local healthcare services more promptly when they moved from another area.

In addition, a number of people living at the service smoked. There were no arrangements in place to support them to stop smoking if they wished to do so.

People received personalised care that was appropriate to meet their needs. However, improvements were needed to ensure people’s needs were more thoroughly investigated before they moved in; to ensure everyone’s individual needs could be met and everyone was safe.

Legally required information was not always reported to, or provided upon request, to the CQC.

Systems were in place to monitor the quality of the service provided however; these had failed to identify and mitigate the risks to one person’s health, safety and welfare during a period of almost 18 months.

People were supported to have sufficient to eat and drink.

Systems were in place to ensure people’s daily medicines were managed in a safe way and that they got their medication when they needed it.

People received effective care from staff that had the right skills and knowledge to meet their needs.

We found that the service worked to the Mental Capacity Act 2005 key principles, which meant that people’s consent was sought in line with legislation and guidance.

Staff were motivated and provided care and support in a caring and meaningful way. They treated people with kindness and compassion and respected their privacy and dignity at all times.

People were given opportunities to participate in meaningful activities.

People were given opportunities to be involved in making decisions about their care and support.

Staff encouraged people to be as independent as possible.

People were also supported to raise concerns about the service and these were responded to appropriately.

You can see what action we told the provider to take at the back of the full version of the report.

We found that suitable arrangements were in place for obtaining, and acting in accordance with the consent of people using the service. People we spoke with were in general agreement with the content of their individual care plans. One person described their morning, and confirmed that everything had happened in accordance with their wishes.

We found that people were supported to have adequate nutrition and hydration. Most people chose to prepare their own meals each day, but people who did have meals provided by the service told us the food was good, and that they had enough to eat and drink.

People were supported by sufficient numbers of appropriately skilled staff. Everyone we spoke with told us the staff were good. One person said: '[the staff] know what they are doing.'

People we spoke with said they knew who to talk to if they had any concerns about the quality of the service being provided to them. Everyone told us they were very happy with the care and support they received. One person told us, 'It is a very nice place to live.'

In addition, records we looked at during our inspection were accessible and generally well maintained.

People using the service spoke positively and told us that the staff treated them well. One person told us that the staff were "wonderful" and another person who told us about the manager describing her as a "top manager" and explained that the support they had received from her had been "life changing".

We observed some positive interaction between staff and people using the service, which showed that staff understood the needs of the people they were supporting.

People confirmed that they felt safe and that their privacy and dignity was respected.