CQC report explained · a nursing home
What the CQC found at Lilbourne Court Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Risks linked to skin breakdown, epilepsy and delayed healthcare recommendations were not consistently managed. Medicines were generally handled safely, but some administration records were incomplete, and people reported staffing and call-bell delays.
- Effective?
- Good
- This question was not reviewed during this focused inspection. Its previous rating was carried forward.
- Caring?
- Good
- This question was not reviewed during this focused inspection. Its previous rating was carried forward.
- Responsive?
- Good
- This question was not reviewed during this focused inspection. Its previous rating was carried forward.
- Well-led?
- Requires improvement
- The provider's checks did not always identify or address risks, and records were not always accurate or clear. A new manager had started an action plan, but the provider's governance systems were not working effectively.
What inspectors found, April 2023
Lilbourne Court Nursing Home was rated Requires Improvement; inspectors found safety risks, staffing pressures and weak checks that needed action.
Inspectors visited on 16 and 20 February 2023 without giving advance notice. They spoke with people, relatives and staff, watched how care was delivered, and checked care, medicine, staffing and management records.
The home was not always safe. Risks linked to weight loss, skin breakdown and epilepsy were not consistently managed. Medicines were generally given safely, but records for some medicines were incomplete. People and relatives also said staff were sometimes too busy, with delays answering call bells.
The home was not always well-led. Its checks had not found some of the problems inspectors identified, and one significant incident was not reported promptly. A new manager had started an action plan, but the overall rating remained Requires Improvement. The inspection only directly reviewed Safe and Well-led, so the other ratings carried over from the previous inspection.
Safeguarding
Staff understood how to respond to abuse concerns. The home investigated concerns and made appropriate referrals to the local authority when needed.
“Where people did raise concerns about their safety, action was taken to investigate and respond appropriately.” from the report
Infection control
Inspectors found the home clean and tidy, with staff following good infection control practices.
“The home was clean and tidy. Staff followed good infection control processes.” from the report
Respect for choices
People said staff listened to them and respected their decisions about daily life and care.
“The staff respect and listen to us. They don't make decisions on your behalf.” from the report
New management action
The new manager was open about some problems and had created an action plan, including a new meeting to monitor health risks.
“An action plan had been created by the new manager to drive forward the required improvements.” from the report
Risks were not consistently managed
seriousHealthcare advice about nutritional supplements was delayed, some people were not repositioned as their care plans required, and one person at risk from epilepsy was not always observed closely enough.
“Risks to people's safety were not consistently managed.” from the report
Staffing and call-bell delays
needs fixingInspectors found times when there was limited staff oversight of shared areas. People described waiting for help, including at night and after using their call buzzer.
“People told us there were not always enough staff.” from the report
Medicine records
needs fixingRecords did not always show why some 'when required' medicines were given or whether they worked. One covert medicine plan had not been reviewed for a significant time.
“However, medicine administration was not always recorded effectively.” from the report
Weak quality checks
seriousThe provider's audits did not identify some health risks, and records did not always clearly show that care had been delivered safely.
“Some of the concerns we found, such as the management of risks to people's health had not been identified by the providers own internal audits.” from the report
Management vacancy and late reporting
needs fixingThere had been no registered manager since August 2022. One significant incident was also reported to CQC late.
“The provider is required to submit notifications to CQC about significant events that occur in the home.” from the report
- 01What has changed in staffing numbers and call-bell response times since the inspection?
- 02How do you now check that people at risk of skin breakdown are repositioned as required?
- 03What arrangements are in place to observe and respond quickly if a person has a prolonged seizure?
- 04How are 'when required' and covert medicines reviewed, and how do you record whether they were effective?
- 05What evidence can you show that the action plan and new clinical governance meeting have improved safety?
This was an unannounced focused inspection of Safe and Well-led only; the other ratings carried over from the previous inspection. This explanation was written from the published report of 12 April 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, March 2020
Rated Requires Improvement; inspectors found kind, personalised care, but risk records, medicines practice and management checks needed improvement.
This was the home’s first inspection. Inspectors visited on 21 and 24 January 2020. They spoke with people, relatives, staff and a healthcare professional, and checked care, medicines and management records.
People told inspectors they felt safe and received kind, respectful care. The home had enough staff, food was well received, the home was clean, and people had personalised care and activities. The effective, caring and responsive questions were rated Good.
The Safe and Well-led questions were rated Requires Improvement. Risk assessments and monitoring were not always accurate or detailed enough. Some medicines were not stored or checked properly, and management systems had not found all these problems.
The manager took immediate action on several issues during or after the inspection. CQC said it would continue monitoring the home and might inspect sooner if concerning information was received.
Kind and respectful staff
People and relatives said staff were kind and compassionate. Inspectors also saw staff supporting people with dignity and respecting their privacy.
“People told us staff were caring and treated them with kindness and compassion.” from the report
Personalised support
Staff knew people’s preferences and supported individual interests, including community activities and hobbies.
“People received personalised care and told us staff were responsive.” from the report
Staffing and cleanliness
People, relatives and staff said there were enough staff. Inspectors found the home clean, tidy and free from unpleasant smells.
“The home was clean, tidy and odour free.” from the report
Training and healthcare
Staff received induction, mandatory training and extra training for conditions such as dementia and diabetes. People were referred to healthcare professionals when needed.
“Records demonstrated staff were up to date with the provider's mandatory training.” from the report
Medicine checks needed improvement
needs fixingSome nutritional products were not stored at the required temperature. Staff also needed to record daily checks that medicine patches were still in place and add clearer instructions for medicines given when needed.
“However, some improvements were required to the management of medicines.” from the report
Management checks missed problems
needs fixingThe home had monitoring systems, but they did not identify all the issues inspectors found. One significant incident was not initially reported to CQC, although action had been taken to keep the person safe.
“However, these had not always been effective in identifying the areas of improvement we found during our visit.” from the report
Some legal and care records were incomplete
needs fixingCapacity assessments were not always specific to the decision and there was little recorded evidence of best-interests meetings. Some care plans also lacked people’s end-of-life preferences.
“However, internal capacity assessments were not always decision specific and there was little evidence of best interests' meetings.” from the report
- 01How are you now checking that risk assessments accurately describe each person’s needs, including epilepsy, repositioning and catheter fluid monitoring?
- 02How are medicines patches checked each day, and how are nutritional supplements and feeds stored safely?
- 03What audits are now in place to make sure care records and health monitoring are complete and accurate?
- 04How do you record decision-specific mental capacity assessments and best-interests meetings?
- 05How are people’s end-of-life preferences recorded and kept up to date?
This was the first inspection of the newly registered home and covered all five CQC questions, with particular concerns about staffing levels and wound care. This explanation was written from the published report of 6 March 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Lilbourne Court Nursing Home
2 rated inspections over 3 years: the service has held its Requires improvement rating throughout.
- April 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Lilbourne Court Nursing Home →
- March 2020Requires improvementSafe: Requires improvementWell-led: Requires improvement
Read what inspectors found at Lilbourne Court Nursing Home →
- April 2019
Registered with the Care Quality Commission on 15 April 2019.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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