Archived: Lillibet Manor

Updated 26 October 2018

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked 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 unannounced comprehensive inspection took place on 01 and 02 August 2018.

The inspection was carried out by one inspector.

We used information the provider sent us in the Provider Information Return. This is information we require providers to send us at least once annually to give some key information about the service, what the service does well and improvements they plan to make. We reviewed other information we held about the service including notifications they had sent us. A notification is information about important events which the provider is required to send to us. We received feedback about the service from the local authority and from another professional who commissioned the service.

During the inspection, we spoke with five people using the service, three staff, the assistant manager and the registered manager. We also spoke with the new manager who had moved from another service owned by the provider to take over the role of registered manager at this service. We met the provider’s nominated individual, and the Director was present when we gave feedback on the second day of the inspection.

We looked at care records for six people to review how their care was planned and managed. We looked at three staff files to review the provider’s staff recruitment and supervision processes. We also reviewed training records for all staff employed by the service. We checked how medicines and complaints were being managed. We looked at information on how the quality of the service was assessed and monitored.

Updated 26 October 2018

This unannounced comprehensive inspection was carried out on 01 and 02 August 2018. This is the first inspection of the service since it was registered under this provider in August 2017.

Lillibet Manor 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.

Not everyone using Lillibet Manor receives regulated activity; CQC only inspects the service being received by people provided with ‘personal care’; help with tasks related to personal hygiene and eating. Where they do we also take into account any wider social care provided. At the time of the inspection, the service was supporting 23 people, but only five received 'personal care'.

Most of the people who did not receive 'personal care' had very complex mental health needs, and we were concerned about the service's ability to meet their needs safely. We shared this information with the commissioners of the service, who had the responsibility to monitor the care that these people received.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission 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 about how the service is run. There were plans for the registered manager to deregistered from this role and a new manager had already started at the service.

People's individual risk assessments were not always robust enough to help staff mitigate known risks. This had the potential to result in unsafe care.

The provider had systems in place to assess and monitor the quality of the service. However, we found further work was necessary to ensure that people’s risk assessments were detailed enough to enable staff to provide safe and effective care. Due to the above issues, we gave the service an overall rating of 'Requires Improvement'. This is the first time the service has been rated ‘Requires Improvement’.

Positively, local safeguarding protocols were being followed by staff and people were not concerned about potential abuse. People’s medicines were managed safely. There were systems in place to ensure that people were protected from the risk of acquired infections.

The requirements of the Mental Capacity Act 2005 were being met, and staff understood their roles and responsibilities to seek people’s consent prior to care and support being provided. People had been supported to have enough to eat and drink to maintain their health and wellbeing. They were also supported to access healthcare services when required.

People were supported by caring, friendly and respectful staff. They were supported to have maximum choice and control of their lives, and the policies and systems in the service supported this practice.

Staff provided support to people in a person-centred way. People found staff to be responsive and sensitive to their needs. The provider had an effective system to handle complaints and concerns. People were supported to pursue their hobbies and interests. People had been given the opportunity to discuss their wishes about the kind of care they would like at the end of their lives.