Lilyrose Care Group Ltd - Cheshire/Derbyshire

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We assessed 5 quality statements in the safe key question and found areas of good practice and concern. The scores for these areas have been combined with scores based on the rating from the last inspection, which was requires improvement. We identified 2 breaches of the legal regulations. Medicines were not always managed safely. We identified examples where documentation was incomplete or not kept up to date in line with best practice and guidance. Where staff had received medicines training, the provider acknowledged they failed to ensure that assessments to check the competency of staff were completed prior to them administering medicines. Following feedback from staff regarding supporting people with medicines, we raised a safeguarding referral with the local authority and requested the provider investigate issues relating to medicines. People told us they were safe. However, risks relating to people were not always assessed and kept up to date. This placed people at risk of harm. Safeguarding concerns were recorded and escalated to the local authority. However, where allegations of abuse had been identified, statutory notifications to the CQC had not always been submitted. The management team were unclear as to their responsibility to notify the CQC of allegations of abuse. Recruitment checks took place. However, these were at times, incomplete, meaning we could not be assured that safe recruitment was taking place. People told us they felt confident if they raised a concern this would be acted upon by the management team. Safeguarding policies and procedures were in place and staff were aware of how to raise a concern. Staff were aware of their roles and responsibilities to safeguard people from abuse.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People felt safe and well supported by staff. Comments included, “I’m well looked after, they are very good to me" and “Overall I am very happy with Lilyrose - they know and understand my needs, and always treat me with dignity and respect." Another person told us, “When there have been issues, I have raised this, and they have been addressed (by managers).”

Overall, staff told us there was a positive culture, where they felt able to raise or share any concerns with managers. Staff were aware of the requirement to report any accidents or incidents and to report where they had concerns. Comments included, “If someone has a fall, we have to call the ambulance first. There is an accident form and body chart we would need to fill in” and “There is a missed medication policy in place, you should fill out a form and tell the office straight away. When the office is informed, they will contact for medical advice.” However, some staff shared some concerns about how new staff were supported in their roles, to ensure they were suitably trained and understood their role. The deputy manager told us medication errors were discussed with staff at team meetings, and new starters had also received further training. However, we saw little evidence of this when reviewing team meeting minutes.

We saw examples of accidents forms, which included where follow up action had been taken in response. For example, one person was referred to their GP following a fall. A log was kept of any accidents, we saw evidence that these had been shared with relevant professionals. However, there was no evidence of a full analysis of these to identify themes, trends and lessons learned, in line with the provider’s policy. People’s care records were not always updated following changes to their support requirements. This meant that staff were not always aware of changes in people’s care. Examples included choking risks, manual handling procedures and risk of pressure ulcers. Following our feedback in relation to improvements required to medication records and care records, the deputy manager took action to address this and discussed learning taken from the inspector feedback. Supervisions took place with staff and we saw some evidence of team meetings that took place. Examples of supervisions included a standard discussion point on safeguarding and developing best practice. However, on examples we reviewed there was nothing recorded in these areas. Feedback forms were completed with people to obtain their views on staff support and to provide feedback on their care. However, we saw little evidence on how this was used to support learning and improvement of the care people received.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

Overall, people told us they were happy with the level of care they received and felt confident to raise concerns with staff and management. We were told, “I do feel safe and supported to understand and manage risks, I am involved in decisions” and “I feel safe and well supported, I would like staff to wear name badges. They [staff] are always respectful and polite, no concerns there.”

Staff told us they felt able to report safeguarding concerns and managers would act on their concerns. Comments included, “First I would speak with my manager. If they don’t do anything, I should go up and talk to CQC.” Adding, “I feel they [managers] would take action; they would definitely do something about it” and “The first thing that comes in is safeguarding service users from abuse and neglect. I understand the issues and know how people can be vulnerable.” Following some feedback from staff we raised a safeguarding alert in response to moving and handling practices and management of medicines. Managers confirmed they had subsequently undertaken further observations and training with staff in relation to individual needs and were in liaison with the local authority. Following the end of the onsite assessment, the registered manager acknowledged work was required to improve documentation around outcomes.

The provider had a safeguarding policy in place. Staff received training in safeguarding as part of their induction and ongoing development. There was a process to record safeguarding concerns with outcomes. However, records were not always robust to demonstrate safeguarding procedures had been followed and outcomes were not always clearly recorded. For example, a complaint previously recorded highlighted safeguarding concerns and an allegation of abuse. However, there was no clear record of all actions taken. The provider confirmed that some action had been taken to address the concerns and they were now evaluating this further in liaison with the local authority. We identified examples where the provider had referred safeguarding issues to the local authority. However, a statutory notification to the CQC had not been submitted. The management team were unclear as to their legal responsibilities. The registered manager, who was also the nominated individual, and deputy manager confirmed they would ensure they fully understood the requirements moving forward. A mental capacity assessment template which included a template for best interest decisions was part of the risk assessment. However, these were not decision specific, as stated in The Mental Capacity Act 2005 (MCA).

We received mixed feedback from people and relatives Comments included, “Care is provided by well trained staff.” and “I am supported to manage risk, happy with care plans.” Another told us, “It is not always clear how [Person] is supported to manage risks.” Adding “changes haven’t been risk assessed (and added to care plan). “

Overall, staff told us they felt they had information about potential risks for people and guidance about how to support them. Comments included., “Before I start with anyone, I reach for the care plan. They (managers) tell you to study the care plan” and “The office will give info about risks. Sometimes they will tell us directly.” The deputy manager told us they used a template to assess risks, which could be added to if other risks were identified. However, records were not always up to date to reflect current risks. During our visit we discussed in detail with the registered manager and deputy manager about the risk assessment process and the types of areas for consideration, for example, when assessing risk of pressure ulcers. The deputy manager was responsive to our feedback and amended the assessments further to ensure these were reflective of people current care needs and risks.

Care plans were in place which included a risk assessment covering different aspects of risk. However, some areas of risk had not been assessed, nor updated following changes to a person’s care. It was not always clear what safety measures were put in place and what impact this had on the person. We asked the provider to review and update risk assessments relating to several people, as the inspector identified care plans had not been updated following changes of people care. Those updated, still did not fully assess all aspects of the risk. For example, a person at risk of choking had not been assessed, or guidance provided to staff about how best to support this person. This increased the risk of people receiving unsafe care. The deputy manager further updated these risk assessments and told us she had benefited from further guidance with this. Following the assessment the provider explained that a new online care planning “Birdie” system was due to be implemented, which they hoped will provide a more effective process for undertaking risk assessments and management plans, as well as keeping these under review. We will review this at our next assessment.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

Overall people told us they were happy with staff and the care they provided. We were told, “Can’t speak highly enough recently, staffing has improved” and “Staff are kind and caring.” However, we also received some feedback over changes of staff, training and language barriers. Comments included, “Staff are competent, but there is a language problem,” “They need more training on moving and handling to support them to be more confident” and “We have had a lot of different staff the last 2 weeks, 15.”

Staff and management told us that staffing levels had improved with further staff recruited following a period of staffing challenges. Staff confirmed they had sufficient travel time in between calls and time to meet people's needs. Comments included, "I have time to get to people on time. There is sufficient time," "There is enough staff to cover but it's quite stretched" and "I have enough time to support people, we have time to have a break". Overall staff felt they received appropriate training. This included a mix of online training and face to face induction training. We were told, "Compared to other experiences I prefer working with Lilyrose, they're more professional with their dealings.” Adding, “No matter if you're in a hurry you must complete your training. They insisted on me completing the courses." Another said, “We do shadowing with new carers, they have in house training with (name) and will do eLearning, they will come on 3 to 5 shadow shifts.” The deputy manager had identified that further support for some international staff was required to support their understanding and development to some cultural differences. A meeting had taken place with some staff to support them in these areas. Staff told us they had the opportunity to have supervision meetings and overall felt well supported. A staff member said, "[Name] is my line manager, yes I have 121 supervision meetings with [Person]." However, some feedback suggested managers had not fully addressed where staff had concerns.

The service used an electronic schedule and logging system for care calls. They had 2 different systems, due to working with 2 local authorities. Schedules were in place for people and staff, with travel time incorporated. Procedures were in place to ensure staff were recruited safely. However, systems were not sufficiently robust. For example, a character reference was not available for a member of staff and the deputy manager re-requested this on the day of the onsite visit to the office, following the inspector raising this to them. We also identified some gaps in recruited staff’s employment history. The provider had not always ensured that any gaps in employment history had been explored and recorded in line with best practice. The deputy manager subsequently confirmed all recruitment records were now fully uploaded onto the system. The deputy manager ensured all supervisions and spot checks were undertaken in line with policy, this being an area of improvement they had identified since being in post. Staff were required to complete an induction which included face to face training, eLearning and shadowing. All staff had completed learning disability and autism training. The care planner systems provided information about when eLearning was next due. During the assessment process the provider ensured all training records were uploaded to the Care Planner system, as there had been some gaps in induction records on the system when we reviewed this. In some cases, staff had completed up to 34 eLearning modules over 1 or 2 days and we recommended further consideration was needed about the expectations for staff around reasonable and maximum completion of modules, to ensure appropriate absorption and reflection of the training. The provider said there had been a focus on getting staff though their training and into the field.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

People and relatives were happy with the level of support staff provided.

Staff views varied about systems to manage the safe administration of medicines. Following feedback, we completed a safeguarding referral was made to the local authority raising concerns about aspects of medicines management . Overall staff told us they received appropriate training and felt supported with this process. Comments included, “We did training, yes, how to go about it (medicines) is in the care plan, you know what the client is taking, you have to identify the tablets” and “Medication, there were 2 trainings part 1 and 2. We can administer as per guidelines. There was shadowing before I started.” The deputy manager was responsive to the issues raised during the inspection and amended records and told us they were addressing areas of improvement with staff.

We raised a safeguarding referral with the LA in response to some concerns raised via staff feedback in relation to medicines management. We found the provider had not always robustly followed their medicines policy. For example, medication competencies were carried out with staff. However, we identified staff who had completed medication training and had not had a medication competency assessment completed with a senior member of staff prior to administering medicines to people. We shared our concerns with the deputy manager who took action to address this with outstanding staff during the assessment period. Medication risk assessments and plans to support people were in place. Medicines administration records (MARs) were also used to record medication administration, but these did not always include the medication name and information about the strength, formulation, or route, in line with best practice guidance. The deputy manager began addressing and amending these following our feedback. PRN (as the need arises) medicines protocols were not sufficiently clear and robust in some cases. Records did not provide adequate guidance to ensure staff knew how and why to administer some medicines, some records were wrong including describing skin creams as "pain relief". Stored stock medicines were not managed or monitored safely. We found that despite MAR audits being undertaken, these only reviewed missing medications or missing signatures. The auditing had not highlighted the issues we have identified. There was a risk that medicines could be administered incorrectly due to incomplete and unclear records. The deputy manager had started to address and amend the information recorded on MARs during the assessment process.