Lillie-Rose Home Care

On this page

• 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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

This is the first assessment for this service. This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

All staff were clear about how to report concerns and had confidence that the provider would address any concerns and make improvements.

One staff member described the process they follow and told us, “This includes speaking with those involved, interviewing witnesses, and reviewing all the available data. Next the incident reports will be immediately reviewed by the Registered Manager or Quality manager and corrective actions are determined to prevent similar incidents from happening in the future. These actions could include changes in procedures, additional training, or improvements to the work environment.”

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

We saw evidence of communication between the management and care staff team and other health care professionals to ensure continuity of care. This included communication with the hospital to ensure people’s care was in place for their return home.

One relative we spoke with said, “[Relative] has had a number of trips to hospital, the staff at Lillie-Rose know I’m working they will track [relative] movements regarding hospital and let me know and arrange to have carer there to receive [relative] when they come home.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

A local authority partner told us about how the provider worked with them to safeguard people, “Staff have contacted me with any concerns they may have regarding a person that is receiving support from them and share all information with me.”

We noted that the provider kept clear records of any safeguarding concerns and made detailed reports to the appropriate external agency including the local authority safeguarding team and the CQC to support people to live in safety.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We saw that care plans identified risks which were discussed with people and relatives where appropriate when carrying out initial assessments and review processes. Care plans contained clear risk assessments and considered people’s capacity, choices and preferences.

Staff had a good understanding of providing safe and enabling care and where to access information about risk. One staff member described this to us, “Care plans and risk assessments provide essential information to manage risk effectively. They outline personalised care tailored to the individual, detailing preferences, routines, and specific needs. For example, they might describe how and when assistance should be provided, such as using specific equipment like hoists or Rotundas for safe transfers or ensuring proper hygiene routines to maintain skin integrity.”

The provider detected and controlled potential risks in people’s home environment. They made sure equipment, staff practice and the number of staff providing care for individuals supported the delivery of safe care.

We saw that care plans and assessments contained information which evidenced the safety of people’s home environment was considered and measures put in place to support people to live in a safe environment.

One staff member told us, “Details of the property the client lives in are in the care plan, if there are any risks in the property, location of mains supply’s, gas, water electric, carbon monoxide detector, stairs furniture bathroom and any equipment used.” Having access to this information meant staff could support people to remain safe and maintain their own safety whilst working.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

We reviewed staff files, training records, induction documents and supervision information. We found the provider followed safe recruitment processes and staff received ongoing training and support which ensured people received support from suitably skilled and experienced staff.

Staff, people and relatives felt staff had the right training to safely meet people’s needs. One staff member told us, “I completed a 3 day in house induction which was a very in depth training including policies, medication, moving and handling training and shadowing out in the field with care calls.” We asked people and relatives if they felt staff were well trained. One relative said, “100%. They [provider] bring out new starters to do shadow visits, it kills 2 birds with one stone, training and 2 way feedback and introduces carer to individual.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

We saw that staff had received training regarding infection prevention and control, use of personal protective equipment (PPE) for example gloves, face masks and aprons, and risk assessments detailed when PPE should be used to protect people from the risk of infection. Staff confirmed they had received training and had access to adequate PPE.

The director told us, “I have strong opinions about the use of PPE, because of the risk of flu and other viruses we still wear face masks for personal care or close contact and always use gloves and aprons.”

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

We saw that staff received training and had an assessment of their competency from the management team before they carried out medicines support independently. Staff confirmed this. The provider had a robust medicines policy to guide staff in line with safe practice and organisational processes.

We reviewed medicines records and found they were completed in full and staff had guidance on what medicines were for and when to administer them, including as required medicines. The management team had oversight of medicines and carried out audits which identified any issues and corrective actions, for example: having a persons medicines delivered to the office so staff could store them safely for the person in their home.