CQC report explained · a residential care home
What the CQC found at Lilford Court
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough staff, safe recruitment, suitable risk guidance and medicines records that were fully completed. They did find that some areas of the houses were not always clean.
- Effective?
- Good
- Staff had training and support for people's individual needs. People were supported with food, health appointments, communication and decision-making.
- Caring?
- Good
- People appeared relaxed with staff, and relatives described staff as kind and respectful. Staff supported privacy, dignity, choice and independence.
- Responsive?
- Good
- Care plans described people's needs, communication and routines. People took part in activities of their choice, including walks, shopping, holidays, voluntary work and day services.
- Well-led?
- Good
- The home had audits, meetings and systems for reviewing incidents and improving care. Some monthly care-plan reviews were missed in August and September because of staff absence and annual leave.
What inspectors found, October 2023
Lilford Court rated Good; inspectors found kind, safe and personalised care, with some cleaning and care-plan review issues to address.
This was an unannounced inspection on 12 and 13 September 2023. Two inspectors spoke with people, staff, relatives and an advocate. They observed care and checked care plans, medicines records, recruitment files, complaints, safeguarding and quality records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe recruitment, suitable training, medicines given as prescribed and care that respected people's choices, dignity and independence.
There were some shortfalls. Some areas were not always clean, and some monthly care-plan reviews had not been completed in August and September. The manager said these issues would be addressed. The inspection was prompted partly by concerns about restrictions and staff knowledge, but inspectors found no evidence that people were at risk of harm from this.
Safe staffing
Inspectors found enough staff to meet people's needs. The home had recruited more staff, reducing its use of agency staff.
“There were enough staff on duty to meet people's needs.” from the report
Medicines
People received their medicines as prescribed. Staff were trained and checked as competent to administer them.
“People received their medicines as prescribed. Medicines administration records (MARs) were fully completed.” from the report
Kind and respectful care
Staff knew people well and supported their dignity, privacy and choices. Relatives were positive about the care.
“We observed positive interactions between people and care staff throughout the inspection.” from the report
Activities and independence
People were supported to take part in activities they chose, develop skills and maintain relationships. This included community activities, holidays and voluntary work.
“They took part in a range of activities of their choice, including going for walks, drives, shopping and film nights.” from the report
Communication with families
Relatives said they were involved in care planning and received information about changes in health or support needs.
“Relatives said communication with Lilford Court was good.” from the report
Cleanliness
minorSome areas needed better cleaning. Inspectors found sticky banister rails and a dining table, as well as discoloured grouting in a shower room.
“Some areas of the houses were not always clean.” from the report
Missed care-plan reviews
needs fixingSome monthly reviews had not been completed in August and September. The manager said the home would catch up.
“Some of the monthly care plan reviews had not been completed in August and September.” from the report
Long-standing goals
minorSome people's goals had been in place for a long time. Inspectors asked the manager to review whether they were still relevant.
“We discussed with the registered manager how some goals had been in place for a long time.” from the report
- 01What action has been taken to clean the sticky banister rails, dining table and discoloured shower-room grouting?
- 02Have all the missed monthly care-plan reviews from August and September been completed?
- 03Which people's goals were reviewed after inspectors found that some had been in place for a long time?
- 04Has the planned maintenance, including fitting a larger bath, been completed?
- 05How are any restrictions, such as locked external doors, reviewed and kept in people's best interests?
This was an unannounced inspection covering all five CQC questions, the care provided and the premises, including infection prevention and control. This explanation was written from the published report of 7 October 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, February 2022
Inspected but not rated; inspectors found strong infection control arrangements, but checks on compliance were not documented.
This was a targeted inspection on 31 January 2022. It looked at infection prevention and control, visiting arrangements and whether COVID-19 staffing pressures affected care. The visit was announced 24 hours beforehand.
Inspectors found that the home had effective arrangements for visitors, testing, personal protective equipment, cleaning, social distancing and safe admissions. Visits were usually held away from the home, with testing arrangements for visitors.
The home was only inspected and not rated. Inspectors were somewhat assured that infection control compliance was audited because checks and actions were not recorded, although the provider said these were carried out.
Visitor infection control
Inspectors were assured that the home had a robust process to reduce the risk of visitors catching or spreading infections.
“We were assured that the provider was preventing visitors from catching and spreading infections.” from the report
Safe visiting arrangements
The home had testing arrangements for visitors and facilitated visits in line with the guidance in place at the time.
“The provider was facilitating visits for people living in the home in accordance with the current guidance.” from the report
PPE and testing
Inspectors were assured that personal protective equipment was being used safely and that testing was available for residents and staff.
“We were assured that the provider was using PPE effectively and safely.” from the report
COVID-19 staffing planning
The provider told inspectors it had measures to manage the risks linked to COVID-19-related staffing pressures.
“The provider told us they had measures in place to mitigate the risks associated with COVID-19 related staff pressures” from the report
Checks were not recorded
needs fixingManagers said they checked cleaning standards and infection risks, and shared actions with staff. However, these checks and actions were not documented.
“However, this was not documented. We have signposted the provider to resources to develop their approach.” from the report
- 01How do you now record infection prevention and control audits?
- 02How are actions from cleaning and infection risk checks recorded and followed up?
- 03What testing arrangements are currently in place for visitors?
- 04How do you manage staffing pressures linked to COVID-19 or other infections?
- 05Where do visits usually take place, and how are infection risks managed during them?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19 staffing pressures; it did not provide ratings for the other areas of care. This explanation was written from the published report of 9 February 2022 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 Lilford Court
3 rated inspections over 7 years: the service has improved, from Requires improvement to Good.
- October 2023Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2022Inspected but not ratedSafe: Inspected but not rated
- April 2018Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- April 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- February 2011
Registered with the Care Quality Commission on 7 February 2011.
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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