Archived: Lillibet Manor

Updated 8 September 2021

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

Inspection team

This inspection was carried out by one inspector

Service and service type

This service provides care and support to people living in a ‘supported living’ setting, so that they can live as independently as possible. People’s care and housing are provided under separate contractual agreements. CQC does not regulate premises used for supported living; this inspection looked at people’s personal care and support.

The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was announced. We gave the service 48 hours’ notice of the inspection. This was because it is a small service and we needed to be sure that the provider or registered manager would be in the office to support the inspection.

Inspection activity started on 08 June 2021 and ended on 21 June 2021. We visited the service on 08 June 2021.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority who work with the service. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.

During the inspection

We spoke with one person who used the service about their experience of the care provided. We spoke with four members of staff including the registered manager, senior care worker and care workers. We reviewed a range of records. This included one person’s care records and medication records. We looked at two staff files in relation to recruitment and staff supervision.

After the inspection

Following our visit, we continued to review a variety of records relating to the management of the service, including policies and procedures, quality and assurance records. We continued to seek clarification from the provider to validate evidence found.

Updated 8 September 2021

About the service

Lillibet Manor is a supported living scheme registered to provide personal care and support, some who may be living with complex mental health needs. The scheme can support up to 34 people in independent, self-contained flats. Each flat provides a kitchen area, bathroom and bedroom. In addition, there is a shared communal garden space, conference room, communal area and two offices. Staff provide support 24 hours a day.

Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do we also consider any wider social care provided. The service was supporting one person with personal care at the time of this inspection.

People’s experience of using this service and what we found

The quality and assurance processes in place did not identify failings of the service, or drive change and improvements.

People spoke positively about the care they received and provided feedback which included, "I live the life of luxury, it is very good, very good indeed."

The provider had completed satisfactory pre employment checks. Staff had the skills and knowledge to support them in their role. People told us, “Staff are trained properly. They are polite and know what they are doing. Staff always consult with me before they do things."

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Staff had received training in infection prevention and control. Staff were knowledgeable of actions they were required to follow to minimise risk of cross contamination of COVID-19. People told us they observed staff wearing appropriate personal protective equipment (PPE). This included facemasks, gloves and aprons.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was requires improvement (published 24 October 2018).

Why we inspected

This was a planned inspection based on the previous rating.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Lillibet Manor on our website at www.cqc.org.uk.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.