Lilyrose Care Group Ltd - Cheshire/Derbyshire

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.

We assessed 2 quality statements in the effective 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.

People were positive over the care of staff, partnership working both internally and externally. External partners spoke positively over contact with the deputy manager and overall, the support provided to people.

We saw evidence of feedback the provider took from people; this was also discussed in feedback from people. However, we did not see how feedback was used to support improvements nor how this was shared with staff.

We assessed 4 quality statements in the well-led 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 one breach of the legal regulations. Governance and quality monitoring was not always effective in identifying and rectifying issues relating to people’s care. Audits and checks had not identified failing we found during the assessment period, relating to people’s risks, medicine, MCA, reporting of incidents to CQC and recruitment practices.

The management team acknowledged the improvements requires in these areas and had taken actions to address some of the failings identified during the assessment. However, these had not been fully completed, or embedded into practice.

The management team discussed challenging around staffing and the focus on safe staffing and ensure that care calls took place over that period, they were focused on making ongoing improvements. The deputy manager acknowledged experience gaps and further learning that was required to support their development, with the oversight of the registered manager.

Overall staff were positive of the support from the management team and being always available when required. Supervisions took place with people and the deputy manager discussed ensuring that more regular teams meeting occur.