Lillibet House

At our last inspection, the service was in breach of legal regulations of the Health and Social Care Act (2014) in relation to safe care and treatment, safeguarding people from abuse, person centred care, safe staffing, dignity and respect, the reporting of notifiable incidents to the Care Quality Commission (CQC) and good governance. At this inspection the service is still in breach of legal regulations in relation to safe care and treatment, safeguarding people from abuse, person centred care, safe staffing and good governance. The service is no longer in breach of the legal regulations in relation to dignity and respect and the reporting of notifiable incidents to the CQC. The service has remained inadequate at this inspection. Please see the full report for details.

Systems continued to not be fully embedded to identify potential safeguarding concerns and take action to safeguard people. People’s risk assessments and care plans continued to not always be up to date with their current support needs or contained generic information about support needs, rather than being specific to people’s needs. People’s daily records continued to not be monitored to make sure support was being given to them in line with their identified needs.

Not all staff had the training they needed to keep people safe. Staff competency checks to help ensure they could support people safely were not effective and actions to support staff to be more effective were not completed. The service continued to not be safe in relation to fire safety. People continued to not be supported safely with their medicines. People continued to not be supported in line with best practice and staff had mixed levels of knowledge to support people with specific support needs. It was not always clear how staff were supporting people to live healthy lives.

People continued to not always be treated with kindness, compassion, dignity and respect and it continued to not be clear how people’s individual preferences were being considered when they were supported. People were not always receiving person centred care, often going long periods of time without meaningful engagement. It continued to be unclear how people and relatives were asked for feedback about the service. Staff did not feel well supported in their job roles and were treated poorly in circumstances such as when they spoke up or when they made an error. Governance systems continued to not be effective in identifying and driving improvements. The service had not had stable management since our last inspection and audits had not been effective in driving necessary improvements. The service had not improved in a lot of areas since our last inspection.

The service continued to be clean, and staff followed good Infection Prevention Control (IPC) measures. Staff continued to contact health professionals and worked well with them when necessary. Mental capacity assessments in place for people were detailed. Staff were kind and caring and wanted what was best for people. People and relatives were mostly positive about their support. Despite our findings the majority of staff tried their best to treat people kindly and give them good experiences. The provider had sought support to start making further improvements such as hiring a consultancy company to start putting audits and measures in place to effectively monitor the quality of the service. There had been some improvements in some areas since our last inspection.

In instances where CQC has decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/or appeals have been concluded.

This service remains in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.