CQC report explained · a residential care home
What the CQC found at Lionsfield House
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 involving fire safety, the environment and the person’s care were not always identified or managed well. Medicines were given as prescribed, but records were not always completed and previous action had not been effective.
- Effective?
- Good
- Needs were assessed before people moved in, staff received training and the home worked with health and social care professionals. Staff supported the person to make choices and promoted least restrictive care.
- Caring?
- Requires improvement
- Staff had positive relationships with the person and treated them kindly. However, some notices and care records did not promote dignity, choice or privacy.
- Responsive?
- Good
- The person’s care involved them, their advocate and other professionals. Staff understood their preferences, supported important relationships and helped them take part in activities they enjoyed.
- Well-led?
- Requires improvement
- Provider oversight was not sufficient during management instability. Audits missed safety concerns, repairs were delayed and staff did not always receive the guidance and supervision they needed.
What inspectors found, August 2022
Rated Requires Improvement; inspectors found kind, effective support but gaps in safety, dignity and management oversight.
This was the home’s first inspection. It was unannounced and took place on 25 July 2022. One inspector spoke with one person and five staff, and reviewed care and medicines records, staff recruitment files, audits and policies. One person was receiving personal care at the time.
The person said they felt safe and staff were kind and respectful. The home provided effective support, worked with health professionals and helped the person keep active and connected with others. Infection control, staffing, recruitment, training and medicines administration were generally managed safely.
However, some risks were not properly identified or managed. These included fire safety, incomplete medicines records and care plans that needed more detail. Some notices and care records did not protect dignity and privacy. Management instability meant checks and staff support had not been reliable.
The overall rating was Requires Improvement. Safe, caring and well-led were rated Requires Improvement, while effective and responsive were rated Good. The provider had to send CQC an action plan, and CQC said it would monitor progress.
Kind relationships
The person had formed positive relationships with staff. Inspectors observed kindness and sensitivity during support.
“The person spoke fondly of the staff who provided their care and we observed they were treated with kindness and sensitivity by staff.” from the report
Effective support
Staff received induction and essential training. The home worked with other professionals to support people’s health and wellbeing.
“Staff completed a programme of training the provider considered essential, which was refreshed at regular intervals.” from the report
Choice and activities
The person was supported to make day-to-day choices and take part in activities and relationships that mattered to them.
“One person told us they spent their time doing what they enjoyed and what was important to them.” from the report
Infection control
Inspectors were assured that infection prevention measures, testing, protective equipment and visiting arrangements were being managed safely.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Fire and environmental risks
seriousA hole in the boiler room ceiling created a risk that fire could spread quickly. Immediate action was taken during the inspection, but the failure to identify the risk showed limited safety oversight.
“The boiler room located in a communal hallway, had a hole in the ceiling which was unsafe.” from the report
Medicines records
needs fixingMedicines were given as prescribed, but staff did not always complete the administration records. Earlier action had not corrected this reliably.
“However, staff had not always completed medication administration records to confirm this.” from the report
Privacy and dignity
needs fixingSome notices restricted people’s choices, and care records were displayed on bedroom doors without enough consideration of privacy and dignity.
“The management and staff team had not considered the display of some care records on the front of people's bedroom doors as being potentially undignified or the impact this had on people's privacy.” from the report
Weak management checks
seriousAudits did not identify some environmental risks, delayed repairs or missing risk assessments. Management instability also left staff without consistent guidance and supervision.
“The provider's systems and processes to monitor the quality and safety of the service were not always effective.” from the report
Care plan detail
needs fixingCare plans did not always contain enough information for staff to provide safe, personalised care, particularly for newer staff.
“Care plan content needed to be improved to ensure they provided staff with the detail they need to provide safe, personalised care.” from the report
- 01What action has been completed to resolve the fire safety risks, and how are these risks now checked?
- 02How do you make sure every medicine administration record is completed correctly and that remedial action is effective?
- 03Have all care plans been rewritten with enough detail for new staff to provide safe, personalised care?
- 04How are staff supervision, training and management cover being maintained after the period of management instability?
- 05How do you now check that repairs, environmental risks and other safety concerns are identified promptly through audits?
This was the first comprehensive inspection of the newly registered home and covered all five key questions, although only one person was receiving personal care at the time. This explanation was written from the published report of 27 August 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 Lionsfield House
Each visit the CQC has published, newest first, back to the day the home was registered.
- August 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- February 2021
Registered with the Care Quality Commission on 25 February 2021.
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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At least 100 live-in carers within about an hour of Coventry
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 £950 to £1,260 a week. 80 can care for a couple. 11 years' experience on average.
“If you bump into her in the night on her way to the bathroom she will still inquire how you are and if everything is alright.”
“My mum would not eat, drink, bath nor sleep without her. In short, she was FAMILY and we loved her dearly”
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