Lilias Gillies House

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

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 changed to requires improvement.

This meant that some aspects of the service were not always safe. We found breaches of regulation in relation to this key question.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

The service did not have a proactive learning culture of learning from incidents to improve service safety. The process for reporting incidents and learning lessons was not well embedded.

Staff did not report all incidents that should have been reported. There were 4 self-harm incidents and 3 violence and aggression incidents for February where an incident report was not completed. There was no rationale as to why a report was not completed. Managers had identified this and had were working with staff to improve this practice at the time of inspection.

Where staff did complete incident reports, they had not always completed all required sections. Part A detailed the incident and completed actions and Part B detailed the clinical formulation, reflections and mitigations of the incident. Part B was required to be completed within 72 hours of the incident. We saw that Part B had not been completed for any reported incidents in February 2026. This meant there was a missed opportunity to reduce further avoidable harm. We raised this with the provider at the time of the inspection; they told us they would be taking action to address incidents not being completed in full.

Processes to learn from incidents and make changes to reduce risks or likelihood if incidents reoccurring were not well embedded. Staff were unable to give us specific examples of learning or change resulting from incidents. Learning from incidents was not discussed in the staff business meeting. Although incidents were investigated by managers and required actions were listed, these actions were not always completed. There was an incident in January 2026 involving fire extinguishers and required actions were for fire equipment to be checked and replaced. This had not been completed by the time of our visit in March 2026.

We could not be assured that all residents were being managed safely in the service. There were a high number of incidents which resulted in calling emergency services and there was a lack of urgency to implement mitigations of risks to residents. There were 18 reported incidents for this service in February, 7 of which were self-harm incidents involving cutting or tying a ligature for the same person. There were 6 notifications of police attendance in December 2025 and at least 2 incidents of a resident attempting to start a fire in the last 12 months. After our visit managers sent us an action plan stating that admissions will be paused to further stabilize the service.

The service did not always notify external bodies, such as CQC, of notifiable incidents. There were 2 incidents in February which required police attendance. These incidents were not reported to CQC, which was not in accordance with their incident reporting policy. Despite this, the service did report safeguarding incidents to CQC.

Residents had an opportunity to discuss and reflect on incidents that had happened in the last week in their weekly community meeting. Staff were also able to reflect on incidents in their weekly reflective practice group.

The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety well.

The service had systems in place to manage referrals and admissions. This included gathering information about a resident and associated risks, to determine if they could be managed safely by the service. The services’ working with risk policy specified that a potential new referral should be assessed using a community matching assessment. This was to understand the potential impact of a new admission on the current resident group. We could not see any evidence of this in the assessment paperwork. The provider informed us that this was discussed in the initial referral multidisciplinary meeting.

Monthly service management meeting minutes showed that managers had recognised that there had been a surge of aggression and incidents and attributed this to the arrival of new residents. One resident told us that their experience of the service had deteriorated after risks posed after recent admissions.

We could not be assured that resident’s substance and alcohol use was being safely managed in this service or that the impact of this on other service users was being monitored and managed appropriately. Staff expressed reservations to us about the recent change in the drug and alcohol policy. Staff were unsure how the policy would operate in day-to-day operation of the service as there was no longer a zero-tolerance approach towards consumption. There was no essential requirement for resident’s to be engaging in a drug and/or treatment programme to reside in the service. Staff reminded residents in the community meeting not to consume substances within the service, but there were no clear interventions to try to limit one resident’s alcohol and substance use. One resident commented that other residents use substances in their bedrooms. Another resident refused to work with the local drug and alcohol treatment service to limit their use of alcohol through a 12-step recovery programme and consumed alcohol within and outside the service. There were 4 incidents which had involved the resident consuming a substance off or on site, 2 of which resulted in harm either to property or another person in the service.

Management of resident smoking was unclear. The service risk assessment specified that residents must have smoking risk management plans present for when they are smoking in their bedrooms, but the drug and alcohol policy specified that residents should not smoke in their bedrooms. Staff had asked senior management to make this policy clearer and residents were asked to be part of this review.

As the service was a rehabilitation service, they did not have any restrictive practices in place or blanket restrictions. This included no search policy at the time of inspection.

We did see evidence that residents met with their GP when required. We also saw that staff held professional meetings with other external agencies when required such as in response to a serious incident or safeguarding concern occurring.

Although we saw examples where the service had identified safeguarding concerns and worked well to manage them, including involving external agencies such as the local authority, this was not always consistent. We also found improvements needed to the accurate recording of mental capacity assessments.

Staff understood how to manage a safeguarding concern once it had been identified but were not always able to determine where a concern would be a potential safeguarding issue. We saw some examples of where a safeguarding concern had been clearly identified and well managed with staff working in partnership with the local authority. However, there were other examples where staff had failed to identify something as a potential safeguarding concern. In incident documentation, 2 out of 5 incidents reviewed showed that there was a safeguarding concern, but the information about escalation safeguarding actions was incomplete.

Where a safeguarding referral to the local authority had taken plane, the referral and actions were reviewed by senior managers in a monthly managers meeting and with staff in the weekly staff business meetings. There were 9 safeguarding concerns raised with the local authority in December 2025.

Staff received training Safeguarding Adults and Safeguarding Children Levels 2 and 3.

Mental Capacity Act

Staff received training in working with the Mental Capacity Act 2005.

We found that the recording of assessments relating to resident’s mental capacity in respect to certain decisions needed improving. The service had already recognised this as an area for improvement. The social worker in the service was responsible for developing this area further.

The service did not have arrangements to monitor adherence to the Mental Capacity Act. Incident forms had a section for mental capacity, which were not completed.

The service did not work well with people to manage risks. They did not always provide care to meet people’s needs that was safe.

We looked at 3 care records during this assessment.

Staff worked with residents to identify and discuss their risks. Staff completed plans to manage these risks. Residents we spoke with were aware of these plans, but 1 resident expressed concerns over agency staff not knowing their risk management plans and said that their keeping safe care plan was not always followed. One agency staff told us they were not aware what the current risks were for the residents. Another resident said they could not always get hold of staff when they were experiencing a crisis, such as a self-harm incident, which was what their plan outlined.

Ligature and self-harm risks were managed through individual risk management plans rather than an environmental audit. Staff made keeping safe care plans which outlined if someone had a risk of using a ligature or self-harming. However, the plans did not detail how staff should manage the risks present in the environment in detail. For example, which areas or parts of the service presented a ligature risk and details of how this would be managed. The plans did not cover all information needed for staff to manage risks as well as they could.

At the time of the assessment, there was 1 resident who needs could not be safely met by the service and had been formally notified of this. The residents care team, external to the service, were looking for a suitable alternative placement. This was currently impacting the experience of other residents, who gave examples of witnessing violence and aggression. Two residents commented that the staff were unable to manage the current risks and incidents had impacted their mental health and they now felt nervous being in the communal areas.

After our visit, the service sent us an action plan which included an action that admissions had been paused pending a review in April due to the instability of the service.

The service did not effectively detect and control potential risks in the care environment and make sure that the equipment, facilities and technology support the delivery of safe care.

Staff carried out some regular assessments of the environment, but these were not always effective or include all necessary areas. Staff completed weekly legionella checks and annual gas safety and electrical safety reports. They also completed a monthly environmental audit to check that the state and cleanliness of the environment. This identified certain areas needed further improvement, such as daily environmental checks not always being completed due to staff shortages. We could not see how this was actioned or signed off through the audit.

Fire extinguisher checks were not part of the daily or monthly environmental checks. This was of concern as there was a recent incident in January, where a resident had attempted to start a fire. During our assessment, we observed that 2 fire extinguishers had been removed from the service and not yet replaced. Two extinguishers that were in place had not received an annual service. We did see appropriate fire safety evacuation signage in the service, informing people where to go if there was a fire. The service had received an external annual fire risk assessment in February and were awaiting the outcome for this assessment.

We could not see any allergies or intolerances listed in the kitchen for residents when they were preparing meals as part of the rota.

Within the service, there were no wall or personal alarm systems, and staff or residents called out for assistance, if they needed it. Residents and staff were aware of this. In the event of an emergency, staff informed us that they would call emergency services and they were very responsive.

The service did not have gender specific areas as it was a community-based service, but all bedrooms were ensuite, so residents did not have to share bathrooms.

Resuscitation equipment was kept in the staff office. Staff could access ligature cutters in the staff office and the clinic room and knew where these were.

Although the service did make sure there were enough staff, they did not always make sure all staff received regular supervision and were up to date with mandatory training.

The service had calculated the number of staff required on site and to manage the service and used consistent agency staff to cover any vacancies. The service had 1 service manager, 1 team leader, 3 therapeutic practitioners, 1 community psychotherapist and 1 community social worker. At the time of our visit there were 8 residents in the service. As 3 therapeutic practitioners had left the service between November 2025 and January 2026, managers were covering these roles with 4 agency staff whilst these vacancies were being recruited to. Staffing numbers were reviewed in the monthly management meetings.

Managers held exit interviews with previous staff to understand the reason for them leaving the service. Reasons included two staff pursuing further academic studies, although one staff member cited the instability of the service. In response to feedback from exit interviews, managers were in the process of updating the job description to provide a more accurate descriptions of roles.

The service had a contractual arrangement with an external agency whereby there were 2 live in care staff who covered day and night shifts. At night there was 1 waking night staff and 1 sleep in staff member to support residents as this was a 24-hour staffed service. The waking night staff was entitled to 2 hours break per shift. During these 2 hours, they put a sign on the office door to say staff on break ring the on-call team for support.

New staff were inducted to the service with a 6-week induction plan, checklist and staff handbook. The induction covered policies and procedures, mandatory training requirement and roles and responsibilities. The service told us they do not have an induction pack for agency staff, but they are verbally inducted into the service upon arrival.

Managers ensured that agency staff had completed the required HR checks to work within this service. Agency staff had received an up-to-date enhanced DBS (Disclosure and Barring service) check to check if an individual has a UK criminal record and is therefore suitable to work with vulnerable adults and children.

We reviewed available information about monthly staff supervision compliance and saw this was 70% in October. Most of the staff we spoke to said they received monthly individual supervision; however, one agency staff we spoke to had started 6 weeks ago and had not received their supervision yet. There was no data available for compliance with annual appraisals. Staff fed back that they felt supported in terms of their self-development. Managers had planned to improve staff supervision and staff development. After our visit, we were sent an action plan highlighting plans for all staff, including agency, to receive fortnightly supervision and introduction of a monthly audit to monitor this. Managers had planned to introduce development plans for staff.

Data we were provided showed that as of December 2025, the overall mandatory training rate for permanent staff was 68%. Managers explained that the rate was low due to the three current vacancies in the service.

Mandatory training covered medicines management, fire safety, cyber security, hand hygiene, equality and diversity, bullying and harassment, mental capacity and deprivation of liberty, health and safety, first aid, safeguarding adults level 2 and 3 and safeguarding children level 1, privacy and dignity, sexual harassment in the workplace, complaints, infection prevention, conflict resolution, lone workers, data protection, whistleblowing, risk management and moving and handling. Three out of 4 agency staff currently working in the service had received were up to date with their training. One agency staff member was overdue on their training for safeguarding adults, safeguarding children, medication, moving and handling and first aid.

There was only one person who was trained in delivering face to face first aid, this was of concern if there was an incident where a resident required first aid support, but the staff trained in first aid was not at work that day.

Specialist training was provided to the staff team. Staff had completed training for caring for people with autism in January 2026. Agency staff told us that they were also offered the opportunity to attend training delivered by the service to permanent staff, such as the caring for people with autism training.

The service provided staff with opportunities to develop their skills and knowledge. Two therapeutic practitioners told us that they were currently completed a Level 7 Mental Health Diploma facilitated by the service.

Managers ensured that staff had access to regular team meetings. Staff attended weekly business meetings and weekly reflective practice meetings. Staff attended weekly reflective practice led by the psychotherapist, which was a supportive and developmental space for staff to reflect on their recent experiences at work.

Managers told us that they dealt with poor staff performance promptly and effectively.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading through effective audit and processes.

Staff completed and recorded daily checks of the cleanliness of the communal areas, including the laundry room and the clinic room. However, this did not include the staff office which had visible dust and cobwebs. This was not part of the regular cleaning schedule.

Residents were responsible for cleaning the communal areas and their bedrooms and there was a daily cleaning group to maintain this. Communal areas were well-furnished and maintained. Staff checked resident’s rooms weekly to ensure that they were clean, although two residents said this could be further improved.

Staff adhered to infection control principles, including handwashing. Staff completed a monthly infection control audit and a monthly kitchen audit to check that the environment was clean and well maintained, although there were no actions listed at the end of the audits to address areas of improvement. For example, the infection control audit had identified that the alcohol hand gel needs to be refilled more regularly, this was not actioned or signed off. We observed that one hand sanitiser was empty. The kitchen audit also identified that the extractor fan and air fryer required cleaning. During out visit, we noticed that the visitor’s bathroom did not have hand wash or paper towels but these were later added.

Staff completed a daily Hazard Analysis and Critical Control Points (HACCP) check to ensure that food was being prepared and stored safely in line with recommended guidelines. Staff had recorded that the fridge temperature monitor for one of the fridges had been broken for over 10 days, but no action had been taken to repair this. We could not see evidence that this had been escalated. We also checked one fridge in the kitchen and there were 2 out of date food items. Staff and residents were reminded in community meetings to dispose of expired food items.

We could not see any allergies or intolerances listed in the kitchen for residents when they were preparing meals as part of the rota.

During this assessment we found that staff did not always follow good practice in medicines management. We found that there was 1 controlled drug that was not stored in the controlled drugs cupboard and was not recorded in the controlled drugs book. Staff were not aware of the location of the controlled drugs book, but this was eventually found in the clinic room. Other medicines were stored and disposed of appropriately and staff checked medicines to ensure that they were in date.

During our assessment we reviewed 6 Medicine administration records (MAR). There was 1 MAR which had not been signed by two staff, which is a requirement to reduce the likelihood of an error occurring when prescribing. This was not in accordance with the medication management policy.

GPs or community psychiatrists were responsible for prescribing the residents’ medicines. There was one resident who was taking a medicine requiring frequent physical health checks and we saw this was completed weekly by the local medicines clinic, but we could not see that this was shared with the service or updated in the resident’s notes, to ensure staff were aware of this.

There was 1 resident who was not compliant with their medicines. Care records did not evidence how this was being managed. The service told us that they have since made a referral to the local community mental health team to receive a review by a psychiatrist.

We could not see evidence of a PRN Protocol in the medicine records. A PRN (pro re nata) is a medicine that is prescribed and given ‘when required’ to treat short term or intermittent medical conditions, so it is not to be given regularly. Each PRN medicine prescribed should have a PRN record for each resident and be kept in the Medicine Administration Record (MAR). This is a called a PRN protocol. Details in the record should include details of medication, precise reason for dispensing, why it has been prescribed and how to give it, how long for if advised by prescriber, the maximum daily amount, and the time to leave in between dispensing must be recorded. This was not in line with their medication management policy.

The clinic room was not equipped with all the necessary emergency drugs. During our visit, we noted that the service did not have Naloxone, which was not in accordance with their drug and alcohol policy. Naloxone is a medicine that rapidly reverses an opioid overdose. This was of concern as there were residents that were actively using substances whilst in the service.

Staff used the daily Hazard Analysis and Critical Control Points (HACCP) form to record the temperature of the clinic room and fridge within the clinic room.

Resident’s had photos in their records, but these did not have their names or date of birth on them, which they should have done. This could cause some confusion when supporting residents to take their medicines.

We could not see any consideration of any possible allergies in medicine records.

Each service had a medicines handbook which was a guide for staff in how to monitor, store and manage medicines. The medicine policy specifies that this should be updated annually but this had not been updated since 2021.

During our visit to the service, we observed a staff member misplace their keys. A resident handed these into us and a staff member later came to retrieve them from us. This was of concern as the keys contained a key to the clinic room where medicines were stored.