The Lilacs Residential Home

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. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 72 (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. The registered manager had systems in place for staff to follow, this included keeping a clear record of accident and incidents and raising safety concerns. Staff received debriefs following incidents so that any learning could be shared and measures taken to keep people safe.

The registered manager understood their responsibility under duty of candour to fully investigate accident and incidents and shared the outcomes of these with relevant parties. Notifications were raised appropriately to the CQC and local council.

We found lessons were learnt to continually identify and embed good practice. This was evidenced in changes made to the environment to keep people safe.
 

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. Before people came to live at the service the registered manager engaged with people, relatives and professionals involved in their care to facilitate a smooth transition to the service. Relatives told us they had an opportunity to view the service and have discussions with the registered manager about the suitability of the service for their loved one. One relative said, “I came and had a look around and felt everything here would be just right.”

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. Staff had received training in safeguarding people and ‘whistle blowing’ and felt confident to safeguard people and raise concerns. One member of staff said, “I would raise concerns immediately.” Safeguarding was discussed with staff during supervisions and staff meetings to ensure they knew how to raise concerns.
The provider shared concerns quickly and appropriately. The registered manager raised any safeguarding concerns with the local authority and worked with them to investigate these fully to keep people safe. Safeguarding notifications were raised to the CQC appropriately by the provider.
 

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. Staff had all the information they needed to support people to manage risks. Care plans and risk assessments were kept up to date and contained information to support staff to mitigate risks to people. For example, risk assessments identified how to support people safely who may be at risk of falling or developing pressure sores. Risk assessments identified how to support people safely who may be at risk of choking when eating and drinking.
Physical health risks were clearly identified in care plans with mitigation in place to support people to manage these conditions safely.
Staff supported people to maintain their independence as much as possible whilst mitigating risks. For example, staff had guidance on how to safely support people who wished to walk with purpose or wanted to access external areas independently.
 

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The registered manager had audits in place to monitor the environment to ensure this was safe for people to live. Staff had training in fire safety and fire drills were undertaken at the service. Each person had a personal emergency evacuation plan in place which showed what support people would need in the event of an evacuation.
Safety certificates were in place for gas safety, electrical wiring and legionella testing. Staff monitored hot water checks and hazardous substances were stored securely.
The provider had a maintenance team who the registered manager contacted should they need anything at the service. We found the service was starting to show signs of wear and tear and was in need of redecoration in places.
The registered manager shared with us plans they had in place and timescales for completion of this. In addition, the provider had drawn up plans to make some structural changes to enhance downstairs space at the service and provider additional access to a first floor bathroom with the necessary adaptations.
 

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. People were supported by a consistent staff team and had a key worker to provide individual support. Staff knew people well and were able to describe how they liked to be supported. The registered manager told us they did not use any agency at the service and had recruited above the number of staff they needed to ensure they could cover any holidays or sickness.
One person told us, “The staff are good, especially that one.” As they pointed and winked at a member of staff.
The provider recruited staff safely, applicants provided a full work history, references and undertook a disclosure and barring check (DBS), to ensure they were suitable to work with vulnerable people.
New staff were given a full induction to the service including completing relevant training and the care certificate for staff new to care. The care certificate is an industry recognised set of standards to equip staff new to care with the skills they need to provide support and care to people. One member of staff said, “I had a full induction when I started and completed shadow shifts.”
New staff were supported through the probation period with regular meetings to discuss their performance and any support they may need. The registered manager had a system in place to monitor staff training and provided face to face training for certain subjects. Where needed, training was repeated yearly and staff competencies were checked.
Staff were being provided with regular supervision to discuss their performance, and any training needs or support they may need. The registered manager held regular staff meetings, from minutes of meetings, we saw staff discussed people they were supporting, the general running of the service and any lessons learned.
 

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. Staff had received training in infection prevention control (IPC) and safe food handling. Personal protective equipment (PPE) was available for staff to use when needed. The provider had policies in place to support IPC practices at the service. Cleaning schedules were in place along with regular audits to monitor the service. There was a cleaner employed and we observed the environment was clean and free from any odours.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Medicine practices had improved at the services. We completed a spot check of medicines and found these to be stored appropriately, and all medicines were accounted for accurately.
Medication documentation we reviewed was in good order and included clear directions for medicine prescribed, as and when required (PRN). There were clear charts in place for the application of creams and patch medicines.
The registered manager completed medication audits to ensure good practice was maintained and followed.