House of the Flame Lily

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 changed to requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulations in relation to people’s safe care and treatment and staff training.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Lessons were not always learnt to continually identify and embed good practice.

There were no systems in place to ensure lessons could be learnt and improvements made to the service where needed. When incidents had occurred, this information was collated on a spreadsheet. On the day of the site visit there was no information to show what action had been taken. After the site visit we were sent the spreadsheet with a ‘lessons learnt ‘column added. The information that had been recorded did not fully consider this. For example, the provider had not considered people’s care records or risk assessments needed to be reviewed after the incidents had occurred and records confirmed these reviews had not taken place. There was no evidence to show how improvements would be made in the future or how this information would be shared with staff.

The provider did not always ensure, establish and maintain safe systems of care.

There were systems in place to ensure people’s needs were assessed before they started using the service. This included both face to face and record-based assessments.

However, people did not always have care plans or risks assessments in place or receive care based on these assessed needs. For example, as reported on under involving people to manage risks 1 person was not always supported by 2 staff as required.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that.

People felt safe being supported by staff. On person told us, “Yes I am safe enough”. A relative said, “I am sure [relative] is safe with them”

There were systems in place to ensure safeguarding concerns were identified, reviewed and investigated, when needed. Staff told us they had received training in this area and records we viewed confirmed this. They were aware what action they should take if there were concerns.

Risk to people had not been fully considered.

Staff told us and records confirmed for 1 person 1 staff member was completing their personal care independently. The person required 2 staff members to complete this, the assessment and care plans in place confirmed this. Furthermore, there was a contingency plan in place for staff to follow when only 1 staff member was available, and this was not being adhered to.

Care plans were not always consistent, up to date or in place. One person had a Percutaneous Endoscopic Gastrostomy (PEG) tube in situ. A PEG is a feeding tube inserted into the stomach for individuals who cannot eat or drink orally. There was no guidance in place for staff to follow around the cleaning and rotation of this. We spoke with staff who told us they cleaned this however confirmed they did not rotate this. This meant we could not be assured staff were following best practice/manufacturer’s guidance when managing this and this placed this person at risk of receiving unsafe and/or inconsistent care.

Other risks to people had not always been fully considered. This included, when a person was using bedrails to mobilise, no risk assessment was in place that considered this. When a person was at risk of choking and eating in bed, there was no risk assessment in place to consider this or guidance for staff to follow to ensure they were in a safe position. When a person was at risk of developing sore skin and required changes of position, there were no records to show this was being completed.

However, we found examples of some appropriate risk assessments that were regularly reviewed.

The provider did not always detect and control potential risks in people’s home environments.

People did not always have individual risk assessments in place related to their environment. Individual risks in people’s homes such as their surroundings had not always been considered to ensure staff were aware of any risks they may be presented with.

When 1 person was using bed rails to mobilise the provider had not considered the risks this may pose to the person and the staff, placing the person and staff at risk of increased risk of injury or harm.

Staff did not always receive up to date training. The provider told us, and the policy confirmed staff should receive non mandatory training annually. We viewed a training matrix for PEG training, and this confirmed some staff had not completed this since 2021. 4 of the 5 staff that had completed this training had not completed this in the last 12 months. Some staff we spoke with confirmed they had not recently received this training. Furthermore, competencies for staff in this area had been undertaken when they completed this training and not since that date. This meant staff may not have had up to date knowledge to support people in this area.

The provider was supporting some people who had a learning disability or autism diagnosis. Records we reviewed and staff confirmed they had not always received training in this area to ensure people received the support they needed.

Staff had received mandatory training as required. Staff spoke positively about the training they received. One staff member said, “We have a lot of training.”

The provider did not ensure there were enough staff available to support people. As reported on under involving people to manage risks 1 person did not have the correct number of staff available at all times to support with personal care. Other people and relatives were happy with how their call times were staffed. One person told us, “They are on time, well depending on the traffic and they do let me know if they are held up.”

Staff had received the relevant pre-employment checks before they could start working with people to ensure they were safe to do so.

The provider assessed and managed the risk of infection.

People and relatives told us staff wore Personal Protective Equipment (PPE). One person told us, “They always wear their PPE.” A relative confirmed, “They all wear PPE.”

Staff confirmed PPE was available, and they had received training in this area. There were processes in place to ensure staff protected people from the risk of cross infection.

Medicines were not always managed in a safe way.

When people had ‘as required’ medicines there was not always guidance in place for staff to follow, this placed people at an increased risk of not receiving the right medicines at the right time.

Staff administering medicines had received training to ensure they were safe to administer these to people.

People and relatives were happy with how they received their medicines and raised no concerns.