CQC report explained · a residential care home
What the CQC found at Lillibet Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were assured about most infection-control measures, including PPE, testing, admissions and visits. They were only somewhat assured about visitor screening and the cleanliness of some cluttered areas.
- Effective?
- Good
- This question was not assessed in this targeted inspection.
- Caring?
- Good
- This question was not assessed in this targeted inspection.
- Responsive?
- Good
- This question was not assessed in this targeted inspection.
- Well-led?
- Requires improvement
- This question was not assessed in this targeted inspection.
What inspectors found, January 2022
Inspected but not rated; inspectors found good infection-control measures, but visitor screening and storage needed attention.
This was an unannounced, targeted inspection on 18 January 2022. Inspectors looked mainly at infection prevention and control, visiting arrangements and whether COVID-19 staffing pressures were affecting the home.
Inspectors found several good measures. These included PPE training, regular testing, cleaning schedules, social-distancing arrangements and support for people to keep in touch with relatives during restrictions.
The home was not given an overall rating or a Safe rating. Inspectors were only somewhat assured about visitor screening and some cleaning arrangements because temperature checks and screening questions had stopped, and some areas were cluttered.
PPE use
Staff had been trained to use PPE correctly, and inspectors saw them wearing suitable PPE for the support they gave.
“Staff were trained to use Personal Protective Equipment (PPE) correctly.” from the report
Testing and outbreak planning
People and staff took part in regular COVID-19 testing. Inspectors were assured that the home could prevent or manage infection outbreaks.
“People and staff took part in regular testing to ensure they identified if they were COVID-19 positive and could take measures to prevent spreading the infection.” from the report
Cleanliness
Cleaning schedules were in place, domestic staff had time to complete their duties and people said the home was well maintained.
“Cleaning schedules were in place and domestic staff told us they had enough time to complete their allocated duties.” from the report
Family contact
The home supported visits in line with restrictions and helped people keep in touch by telephone or video call when face-to-face visits were not possible.
“When face to face visits were not able to go ahead people were supported to stay in contact using telephone and video calls.” from the report
Visitor screening
needs fixingThe home had stopped temperature checks and COVID-19 screening questions for visitors. Management said these would be put back in place after the inspection.
“The provider had stopped taking temperature checks or asking COVID-19 screening questions for visitors to the service.” from the report
Clutter and storage
needs fixingSome areas were cluttered because of limited storage space. Inspectors said this made them difficult to clean effectively.
“Due to lack of storage space some areas of the service were cluttered making them difficult to clean effectively.” from the report
- 01Have temperature checks and COVID-19 screening questions for visitors now restarted?
- 02What changes have been made to provide more storage and remove clutter from areas that need cleaning?
- 03How are you managing COVID-19-related staffing pressures, and have these affected people's care?
- 04How will relatives be supported to visit if face-to-face visits are restricted again?
- 05What infection-control measures are currently in place for new admissions and visiting professionals?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19-related staffing pressures; it did not assess the other key questions and gave no overall rating. 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.
What inspectors found, July 2019
Lillibet Lodge was rated Good overall, but inspectors found leadership needed improvement and some respectful language and activity planning fell short.
This was an unannounced inspection on 06 June 2019. One inspector and an Expert by Experience visited. They spoke with people, relatives, staff and the registered manager, observed care and checked records, medicines, complaints, audits, accidents and staff files.
The home was rated Good for Safe, Effective, Caring and Responsive. Inspectors found enough staff, safe medicines systems, suitable training, good access to healthcare, kind care and support that met people's individual needs.
The home was rated Requires Improvement for Well-led. Inspectors heard staff use disrespectful language about some people and found a missed opportunity to involve people in an important local celebration. More information about people's end of life wishes also needed to be added to care plans.
The overall rating was Good. This was an improvement from Requires Improvement at the previous inspection, published on 08 June 2018. However, the Well-led rating had fallen from Good to Requires Improvement.
People felt safe
People told inspectors they felt safe. Staff knew how to recognise and report safeguarding concerns, and records showed concerns were reported promptly.
“I trust the staff here and they make me feel safe. I have never heard anything untoward here.” from the report
Safe staffing and medicines
Inspectors found enough staff to support people safely. Medicines were received, stored, given and recorded safely, with staff training and competence checks.
“Medicines were received, stored, administered and disposed of safely.” from the report
Kind and respectful care
People and relatives described staff as kind and friendly. Inspectors observed positive interactions and found that staff supported privacy, dignity and independence.
“We observed friendly and respectful interactions between people and staff. Everyone seemed happy and comfortable.” from the report
Improved staff skills
The home had improved staff training and supervision. Staff had the information and skills needed to support people's health and care needs.
“We saw improvements had been made to the quality of staff training.” from the report
Improved monitoring
The provider had strengthened its audits, governance and electronic care records since the previous inspection. Inspectors found evidence that the provider had acted on earlier findings.
“We saw evidence of learning from the findings of our previous inspection and improvements had been made.” from the report
Respectful language
needs fixingInspectors heard staff use the term 'feeders' when referring to people who needed help to eat. The manager said this would be addressed with staff.
“For example, on three occasions, we heard staff referring to people who needed support to eat as 'feeders'.” from the report
Meaningful activities
minorInspectors found a missed opportunity to involve people in D-Day celebrations. The home also needed to do more to ensure activities were meaningful to individual people.
“We discussed with the registered manager about a missed opportunity to engage people in D-Day celebrations which were happening at the time of the inspection.” from the report
End of life wishes
needs fixingAlthough end of life support was included in care plans, inspectors said people's wishes were not always recorded. The manager said this information would be added.
“Further work was necessary to ensure people's end of life care wishes were included in their care plans.” from the report
- 01What action have you taken to stop staff using disrespectful terms such as 'feeders'?
- 02How do you identify and provide activities that are meaningful to each person?
- 03Have all residents' end of life wishes now been discussed and recorded in their care plans?
- 04How do managers check that the improvements to quality monitoring and care records continue?
- 05How are people and relatives involved in reviewing care plans and giving feedback about activities?
This was an unannounced planned inspection that looked at all five CQC questions, including care, safety, records, staffing and leadership. This explanation was written from the published report of 10 July 2019 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 Lillibet Lodge
3 rated inspections over 2 years: the service has improved, from Requires improvement to Good.
- January 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- July 2019Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- April 2017Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2016
Registered with the Care Quality Commission on 22 July 2016.
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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
88 live-in carers within about an hour of Bedford
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,260 a week. 76 can care for a couple. 12 years' experience on average.
“We can all fully relax around Nyarai and she feels like part of our family, which is no mean feat!”
“She handled the new situation in front of her with such professionalism and I felt I could trust her 100%.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.