Lilleybrook Care Home

“We saw inconsistencies in records such as care plans and risk assessments, which required updating. Some care plans lacked key information regarding the management of risk, and we did not always see a clear record to demonstrate how decisions had been taken in relation to risk.”

“There was a governance structure in place to support the provider and management team to undertake their roles. However, the governance systems we saw at the time of assessment had not been consistently operated to effectively monitor the service and identify the shortfalls we saw in relation to care planning and medicines.”

“We received mixed feedback from people, relatives and professionals about whether there were always enough staff available to support people’s needs. We raised this with the provider who showed us how they had had calculated their staffing levels to ensure there were enough staff to meet people’s needs.”

“People were supported to make choices, maintain independence and engage in meaningful activities. Feedback about the improved activities programme was particularly positive, with people describing increased enjoyment, laughter and social engagement. Staff recruitment processes were safe. Infection prevention and control measures were effective, and the environment was well maintained and adapted to meet people’s needs.”

“This inspection found the provider to be in breach of legal regulations relating to safe care and treatment and good governance. In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.”

“The provider and registered manager were responsive to all issues raised during this assessment, and the leadership team put immediate measures in place to make improvements where they agreed there were shortfalls.”