CQC report explained · a nursing home
What the CQC found at Lilleybrook Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, May 2023
Lilleybrook Care Home was rated Good; inspectors found safe, responsive care and clear improvements under new management.
This was an unannounced focused inspection on 26 and 27 April 2023. Inspectors reviewed Safe, Responsive and Well-led. They spoke with people, relatives, staff and a healthcare professional, and checked care records, staff files and management records.
The home was rated Good in all three areas inspected. Inspectors found enough staff, safe medicines, suitable risk assessments and improved personalised care. They also found effective checks on the quality of care and action taken when things went wrong.
Some fire doors did not close properly during a test, but immediate work was carried out. People and relatives also said activities had previously been limited, although new activity staff and plans were being put in place.
The overall rating improved from Requires Improvement at the last inspection. The report says earlier breaches about personalised care and quality monitoring had been resolved.
Staffing
Inspectors found enough staff to meet people's needs. Staffing had improved, with less reliance on agency staff and sickness cover.
“Suitable staffing levels were in place to meet the needs of people using the service.” from the report
Personalised care
Staff understood people's choices, communication needs and risks. Care had improved since the previous inspection and was no longer in breach of the earlier regulation about meeting people's needs.
“Improvements had been made regarding people's personal care and the service was no longer in breach of regulation 9.” from the report
Learning from incidents
The management reviewed accidents, incidents and a choking episode to reassess risks and improve care.
“Following a choking episode in the home, the service had carried out a full review of people's choking risks” from the report
Quality monitoring
The provider used audits and a service improvement plan to track concerns and check that actions had been completed.
“The provider and management team undertook a range of quality assurance audits to ensure a good standard of service was maintained.” from the report
Fire doors
needs fixingSome fire doors did not close after a fire alarm test during the inspection. Immediate work was carried out to protect people, but families may want to check that the wider fire safety work is now complete.
“During the inspection, some fire doors were identified not to close following a fire alarm test.” from the report
Activities
needs fixingPeople and relatives said activities had been limited before the inspection. More activities were being introduced, but this improvement was still developing.
“There are some activities, but they are limited, maybe a few singsongs but I am okay at the moment.” from the report
End of life records
minorThe manager identified that records could be improved for people's end of life preferences and support for relatives at that time.
“improvements could be made in recording people's end of life care preferences and how they supported relatives at this time.” from the report
- 01What activities are now available each day, including one-to-one activities for people living with dementia?
- 02Has all the remedial fire safety work been completed, and when was the work last checked?
- 03How are staffing levels adjusted when the home is full or people's needs change?
- 04How are people's end of life preferences recorded and kept up to date?
- 05How will you show that the improvements from the previous Requires Improvement rating are being maintained?
This was a focused inspection of Safe, Responsive and Well-led; the other key questions were not inspected and their ratings were carried over from the last comprehensive inspection. This explanation was written from the published report of 31 May 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, January 2022
Lilleybrook Care Home was rated Requires Improvement; inspectors found caring staff but delays in personalised care and weak management checks.
This was an unannounced focused inspection on 7, 8 and 9 December 2021. Inspectors looked mainly at whether care was responsive and whether the home was well-led. They also checked infection prevention and control.
Some people and relatives had good relationships with staff, and staff were described as committed. However, inspectors found that people did not always receive care when they needed it or in line with their wishes. Some people waited for support, basic care was sometimes missed, and activities were not available consistently.
The home had recently changed management. Important records, including complaints, cleaning checks and call bell records, were not always available, complete or reliable. The overall rating fell from Good at the previous inspection to Requires Improvement. The home breached Regulation 9 on person-centred care and Regulation 17 on good governance.
Good relationships
People and relatives generally had positive relationships with staff. Staff were described as professional, caring and committed despite the difficult circumstances.
“Generally the [staff] are lovely. Mostly quite delightful.” from the report
Communication needs
People's communication needs were identified and recorded. The report says reasonable adjustments were made where appropriate.
“People's communication needs were identified, assessed, and recorded in care plans.” from the report
End-of-life support
The home had arrangements for healthcare support and comfort at the end of life. Visiting arrangements followed COVID-19 guidance.
“People were supported at the end of their life by care staff and other healthcare professionals where required.” from the report
Infection arrangements
Inspectors were assured about several infection control measures, including testing, safe admissions and managing outbreaks.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Care was sometimes delayed
seriousPeople sometimes waited for help and did not always receive care in line with their wishes. Inspectors also saw people waiting for support when staff had to leave their unit.
“People did not always receive timely, personalised care.” from the report
Basic care and activities were missed
needs fixingFeedback included concerns about washing, dental care, clothing and continence care. Some people also spent long periods without activities or individual time.
“We do our best but can't give people the care they deserve. We can't spend any time with people.” from the report
Management records were unreliable
seriousThe provider could not readily find some records and its checks had not identified important gaps. This meant leaders did not have all the information needed to monitor care properly.
“Monitoring systems were not always effective as the records supporting the management of the service were not always reliable.” from the report
- 01What has changed since the inspection to make sure people do not wait for washing, dressing, hoisting, food, drinks or continence care?
- 02How do you check that care is being delivered according to each person's choices and care plan?
- 03How many activities are now available, and how do you support people who are bed bound or at risk of social isolation?
- 04How are complaints, cleaning checks, call bell records and fluid records now stored and reviewed?
- 05Who is managing the home while a registered manager is not in post, and how are relatives' concerns recorded and acted on?
This was a focused inspection of Responsive and Well-led, with infection prevention and control checked under Safe; Effective and Caring were not inspected and previous ratings were carried forward. This explanation was written from the published report of 25 January 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 Lilleybrook Care Home
9 rated inspections over 8 years: the service has improved, from Requires improvement to Good.
- May 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2022Requires improvementSafe: Inspected but not ratedResponsive: Requires improvementWell-led: Requires improvement
- February 2021Inspected but not ratedSafe: Inspected but not rated
- February 2020Goodup from Requires improvementSafe: GoodResponsive: GoodWell-led: Good
- January 2019Requires improvementstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- June 2017Requires improvementstayed Requires improvementSafe: Requires improvement
- December 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- March 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- June 2015Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Good
- September 2014
Report published without a new overall rating.
- May 2014
Report published without a new overall rating.
- April 2014
Report published without a new overall rating.
- October 2013
Registered with the Care Quality Commission on 15 October 2013.
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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