The Lilacs Residential Home

The provider had governance arrangements in place. A regular auditing and quality assurance system was completed by the provider and service management. Whilst we identified governance and quality assurance systems were mostly effective, improvements were required to the monitoring of recruitment processes, medicines storage and emergency evacuation planning.

The provider promoted a positive safety culture. Incidents and accidents were appropriately reported, recorded and reviewed. The service used an electronic care system that contained key information about people’s care needs and risk assessments to promote people’s safety and improve outcomes.

There were systems to ensure ongoing care continuity from admission and in the event of planned or unplanned hospital admissions. Safeguarding procedures were understood by staff and appropriate records were maintained. Where required, safeguarding referrals had been made with the local authority.

Regular environmental checks were carried out to ensure the premises remained safe and well maintained. There were sufficient staff on duty to ensure people’s needs were met in a timely way. New staff received an induction when commencing employment. Staff received appropriate training and supervision.

Infection prevention and control measures were well managed, and the environment was clean. Medication administration records reviewed during the assessment were fully completed, with no missing documentation, and stock levels were accurate.We identified minor storage concerns with liquid medicines that were highlighted to the service management.

There were appropriate systems and processes to ensure people were only deprived of their liberty with the appropriate legal framework in place. Where required, the provider operated in accordance with The Mental Capacity Act 2005.

We observed people were treated with kindness and respect. Relatives were welcomed and people were encouraged to make choices and remain as independent as possible. There were systems and processes to seek the views of people and their relatives. Where required, end of life care was appropriately planned to ensure the service acted in accordance with people’s wishes and preferences.

There was a service improvement plan to promote continual development and improvement. The service had established links with the local community to improve the quality of life for people living at the service.