Background to this inspection
Updated
24 August 2023
Inspection team
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 Health and Social Care Act 2008.
As part of this inspection, we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
Inspection team
The inspection was completed by 2 inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.
Service and service type
Lilybank Hamlet Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and we looked at both during this inspection.
Registered Manager
This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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.
At the time of our inspection there was no registered manager in post, however a new home manager told us they intended to submit an application to register as the manager.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.
During the inspection
Inspection activity started on 06 June 2023 and ended on 15 June 2023. We visited the service location on 06 June 2023. We spoke with 5 people who used the service and 9 relatives about their experience of the care provided. We spoke with 5 members of staff including a manager, senior care worker and care workers.
We reviewed a range of records. This included care records for 4 people and multiple medicine records. We looked at 2 staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were also reviewed.
Updated
24 August 2023
About the service
Lilybank Hamlet Care Home is a residential care home providing personal care to up to 63 people. The service provides support to people with dementia, older people and people with a learning disability. At the time of our inspection there were 32 people using the service.
The home is set over 3 floors with a lounge, dining room and conservatory on the ground floor and further communal spaces to the second floor. There was a mixture of ensuite and shared bathroom facilities and there was access to outdoor space.
People’s experience of using this service and what we found
We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.
Right Care: Identified risks to people's safety were not always mitigated to keep people safe from avoidable harm. Governance systems were not effective in monitoring risks to the health, safety and welfare of people using the service.
Systems and processes were not effective in maintaining and inspecting equipment accessories used to lift people. Medicines were not always managed safely; medicine protocols were not always in place for the administration of when required medicines. Fire safety actions were not completed, fire procedures were not updated, evacuations were not reviewed with actions to improve, and staff had not been trained in the use of fire equipment.
People received kind and compassionate care. Staff protected and respected people's privacy and dignity. Family members felt that their relatives were safe at the service. Appropriate checks were carried out when recruiting new staff to support people. People could take part in activities and were supported to access their community.
Right Culture: The service had recently gone through several changes, including a change of leadership. More time will be required to assess whether the leadership in place ensures people have inclusive and empowered lives. People felt able to raise concerns and felt that the management team were approachable.
Right Support: Staff had received training to support people with a learning disability. The provider recently closed a small home at the location and supported peoples transition into other placements or into the main home. The provider had worked with other agencies to coordinate and plan the transitions for people.
People were supported to have maximum possible 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.
The service did not always demonstrate how they were meeting the principles of right support, right care, right culture.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was requires improvement (published 17 March 2023).
At our last inspection we found breaches of the regulations in relation to safe care and treatment and governance. The provider completed an action plan after the last inspection to tell us what they would do and by when to improve.
At this inspection, we found the provider remained in breach of regulations.
Why we inspected
We carried out an unannounced comprehensive inspection of this service on 06 June 2023. Breaches of legal requirements were found in relation to safe care and treatment and good governance.
We undertook this focused inspection to check if the provider had made improvements and if they were now meeting the legal requirements. This report only covers our findings in relation to the key questions Safe and Well-led.
For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.
The overall rating for the service has not changed following this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Lilybank Hamlet Care Home on our website at www.cqc.org.uk.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
Enforcement
We have identified continued breaches in relation to health and safety, fire safety, governance and medicines management.
Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.
Follow up
We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.