Lilyrose Care Group Ltd - Staffordshire

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question Good. At this assessment the rating has remained Good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The provider’s vision of providing a good service to people by a caring staff team was shared across the staff group. Staff told us they were committed to providing a caring service to people which made a positive difference to their lives. This was confirmed by the positive feedback we received from people and relatives.

Relatives valued transparency through access to the provider’s digital records. One relative said, “We have access to the digital records where staff record activity and also log in and out times. This gives me peace of mind.”

The provider promoted a culture of openness, diversity and inclusion within the service. Staff were able to approach the registered manager or provider if they had any concerns to raise and were encouraged to understand and learn people’s diverse needs.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

People and their relatives spoke positively about the management team and office staff. They told us the service was managed well, and the management team were accessible and responsive. One relative said, “The management team pay attention to detail and communicate well with me,” and another commented, “The carers and manager listen to me.” This open communication and responsive leadership helped them feel informed and involved in their relative’s care.

People and relatives told us the service was well run and praised the approachability of the management team. One relative said, “The company is well run, and the manager is easy to speak to.” Without exception people and relatives told us they would recommend the service based on their experiences. One person said, “The carers are well trained, and I highly recommend the company.” A relative said, “They are very good and I highly recommend them.”

Staff told us they felt supported in their role and received supervisions to ensure any issues or areas of development were discussed. There was a schedule of supervisions in place to ensure staff had regular opportunities to discuss their role.

The registered manager ensured they remained up to date on good practice and expected standards through a number of avenues such as, skills for care, local provider meetings, local authority and CQC communications, which are discussed in senior management meetings and disseminated to staff.

The registered manager understood their responsibilities of their registration with us. They had notified us of events that had occurred at the service and were open and honest when things went wrong, responding to the feedback provided.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff understood how to speak up and told us they were able to raise concerns easily and told us the care co-ordinators and registered manager were approachable. Staff understood how to follow the provider’s whistleblowing policy, which was accessible to them. One staff member said, “Managers encourage everyone to speak up against any form of abusive or safeguarding issue including whistleblowing.”

The registered manager held team meetings which provided an opportunity for staff to raise practice related issues and discuss ways to improve. One staff member said, “Team meetings are held and the office is always welcoming to share concerns or ideas.” The records we viewed confirmed what staff had told us.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider promoted a diverse and inclusive workforce, ensuring all people were treated in a fair and equal way. This included recruitment processes which actively encouraged a diverse staff group. This inclusive staff culture within the service helped to ensure staff were aware of the importance of the diverse needs of both the workforce and the people they supported.

The provider ensured the individual needs of all staff were respected and made adjustments to ensure they were able to access cultural and religious events that are important to them. For example, rotas were devised to ensure as many staff as possible were able to attend cultural events such as Ramadan, Diwali and Eid.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The provider had governance systems in place to monitor the service and identify areas which required improvement. This included audits in complaints, safeguarding and accident/incidents, which detailed the nature of the concerns, the action taken by the registered manager to ensure improvements were made to the service provision.

However, these were not consistently recorded in a way which enabled trends to be highlighted. For example, Medicine Administration Records (MARs) were regularly audited, action had been taken such as discussions in staff supervision and records were updated, but there was not a central document to enable analysis of ongoing audits to identify consistent ongoing errors or issues. We did not find any concerns with medicine management, and there was no impact on people. However, we fed this back to the provider who took onboard our feedback to ensure they had consistent systems in place to provide an overview of the service.

The service had a clearly defined management structure, and leaders had developed an action plan which set out specific improvement priorities and timescales. This helped ensure that ongoing improvements were monitored and delivered effectively.

The provider had a contingency plan in place to ensure people continued to receive their care when events out of their control happened, such as adverse weather. Staff were aware of this and understood when changes may be needed to the way they worked to ensure continuity of care.

Records we viewed such as team meetings and supervisions demonstrated the registered manager shared good practice guidance and updates in the required standards of care with staff. This ensured staff had the most up to date information to follow when providing care to people.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The registered manager had developed good working relationships with a range of professionals to ensure people received consistent care and their needs were reviewed when needed. This included health and social care professionals to ensure people’s care needs were discussed and reviewed to provide joined up care.

The registered manager was open to feedback from other professionals to help continually improve the service people received and displayed openness to learning from feedback. They said, “I welcome feedback from other professionals, it helps us to learn new things and make improvements to the service.”

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The provider completed regular supervisions, appraisals and spot checks which enabled staff to discuss any issues within their role and to promote continuous learning and development. Some staff told us the provider encouraged them to develop their skills and knowledge to assist them to support people effectively. One staff member said, “Staff are encouraged to take on other learning such as NVQs.”

The provider reviewed incidents, accidents, safeguarding and complaints to share learning and good practice with staff which ensured improvements were implemented when needed.