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 Good. At this assessment the rating has remained Good.

This meant people were safe and protected from avoidable harm.

This service scored 66 (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 identify and embed good practice.

The provider had systems in place for staff to follow after an accident, incident or adverse event. This included keeping records and raising safety concerns where appropriate. Accidents and incidents were subject to monitoring and oversight by management and the provider. Learning was shared with staff within the service, and where appropriate, other services operated by the provider. A healthcare professional told us, “The Lilacs team have worked hard with the primary care team to trial a new falls pathway and assessment with the primary care team.They have responded positively to suggestions and provided accurate records for audit which showed a significant reduction in falls.”

The management 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.

The provider worked well with people and healthcare partners to establish and maintain safe systems of care. However, we identified they did not always manage or monitor people’s safety consistently.

People had individual Personal Emergency Evacuation Plans (PEEPs) within their electronic care records to aid them in being safely evacuated from the service in the event of an emergency. However, we identified 3 people’s full PEEPs were not present within the emergency fire folder. They were recorded on the overall occupancy list; however, the absence of a full PEEP may delay an evacuation.

People had access to a range of health and social care professionals when needed. Documents were in place to support people when they moved between care services.An electronic care planning system helped to monitor people’s care and support needs and identified when support was needed from external professionals.The provider worked collaboratively with healthcare professionals, including GP’s and district nurses, to ensure people received consistent and joined-up care.

There were processes to ensure continuity of care. For example, if a person was admitted into hospital, key information hospital staff may need could go with them.

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.

People felt safe living at the service and spoke positively about the care and support they received.Staff received appropriate training and were able to provide examples of signs that may indicate abuse or neglect and could also explain how they would escalate concerns.

There were systems to ensure people were protected from the risk of harm, abuse or discrimination. The provider worked with safeguarding agencies where required and relevant information was shared. The provider had raised concerns with the local authority where safeguarding concerns had been identified.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service.

We found the provider had systems and processes to monitor approved and pending DoLS applications. There was a tracker which showed where DoLS had been approved and others that were pending with the relevant local authority.

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.

The provider had appropriate systems to assess, identify and mitigate risks to people. Risks were assessed in a person-centred way, with care plans clearly outlining the support people needed. These were regularly reviewed and updated to reflect people’s changing needs.Where people had specific health needs which placed them at risk of harm, risk assessments had been completed and the risks relating to the condition had been considered.

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 provider undertook regular audits to monitor the safety of the home environment and equipment. There were dedicated maintenance staff who monitored the environment. Fire equipment and emergency lighting were tested regularly to ensure it was in good working order. There were also water temperature checks, legionella testing, gas safety certificates, electrical hard wiring and portable electrical appliance tests. We identified some checks were overdue as they were last completed in May 2026. We were advised this was due to a current vacancy and staff sickness, but the checks were scheduled to be completed.

We discussed an environmental concern in relation to unrestricted access to all staircases within the service. The deputy manager told us this risk was managed through environmental and personal risk assessments, and no current restrictions were identified as needed.

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. However, we identified one person’s recruitment process had not been fully completed prior to them commencing employment.

Most staff were recruited safely with appropriate checks taking place to ensure their eligibility to work and suitability to work with vulnerable adults. We saw within 1 new staff members file, all appropriate pre-employment checks relating to eligibility and Disclosure and Barring Service (DBS) checks had been completed. However the staff member had commenced work whilst the provider was still awaiting a required reference. No risk assessment had been undertaken to evidence how this potential risk was managed. We identified this to the provider and immediate action was taken.

Staffing rotas were based on the needs of the people living at the service and were planned in advance to identify shortfalls. Systems were in place to respond flexibly to shortfalls and maintain safe staffing, which included the use of agency staff.No concerns were raised by people, their relatives or staff in relation to staffing levels. One staff member said, “Yeah, I do feel there are enough staff here.”

There was an appropriate induction in place for new staff. The provider had a continuous training programme in place for staff. Training was delivered by the provider’s dedicated training staff where required. Staff spoke positively about this and how it supported them in their roles. Staff received supervision which discussed their performance and progression opportunities.

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.

People told us the service was clean and well maintained. Housekeeping staff worked effectively to maintain a high standard of cleanliness. Records showed cleaning schedules were in place and consistently followed to ensure all areas of the service were clean and well maintained.

Staff understood their responsibilities in reducing the risk of the spread of infection and had received appropriate training. We observed there was Personal Protective Equipment (PPE) such as gloves and aprons available for staff to access throughout the service and staff used the PPE appropriately where required.

The provider made sure that medicines and treatments were generally safe and met people’s needs, capacities and preferences. However, we identified improvements were required in relation to storage of some medicines.

The management had put systems in place for staff to record the opening dates on liquid medicines, however this had not always been followed. Whilst we did not identify any impact on people, there was a risk medicines could be used outside of the manufacturer’s recommended storage guidelines as it was not always clear when some medicines had been opened. This was highlighted to management.

Systems were in place for the safe ordering and administration of medicines, and staff were clear about their responsibilities. The electronic medicines system provided 4 daily updates to management to provide oversight if medicines had been administered. This reduced the chances of medicines being missed. Guidance and protocols were in place for medicines to be safely administered to people ‘when required’ (PRN), such as paracetamol. Staff had received training in the safe administration of medicines, and their competency was assessed periodically by the service management.

Medicines were stored securely and regular temperature checks of these storage facilities were carried out to ensure medicines were kept safe and within manufacturer’s guidelines. Medicines that required additional security measures around storage were stored appropriately and stock balances checked were accurate.