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 44 (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 may need 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. Some people had a transition plan in place to support a safe transfer to the service.

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 staffing it was unclear how people’s individual hours were delivered in the supported living environments.

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, “I feel safe with them”. A relative said, “Really happy with it, [relative] is safe”.

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.

Care plans were not always consistent, up to date or in place. For example, 1 person used a mobility aid to safely transfer around their home. A care plan and risk assessment were in place for this, however it had not considered all risks including the stairs in the person’s home and the uneven outdoor areas.

Other risks to people had not always been considered to ensure they followed the right support, right care, right culture guidance or considered the Reach Standards. These are a set of 9 voluntary standards designed to promote person centered support for individuals with learning disabilities and/or autism particularly in a supported living setting. For example, we saw people’s medicines were stored together in a medicines room in the supported living scheme. Individual risk assessment had not considered the rationale for this, the restrictions this may have on people or the individual risks this posed for people.

However, we found other 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.

The garden we viewed was uneven and cluttered, there was no risk assessment in place to consider how people with poor mobility needs may access this, and the risks people may be exposed to.

Staff did not always receive up to date training. The provider told us and we saw the policy in place stated staff should receive non mandatory training annually. We viewed a training matrix for epilepsy training, and this confirmed some staff had not completed this since 2023. 5 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 always ensure there were enough staff available to support people. People living in supported living had assessed individual hours. It was unclear how these hours were being delivered to people. Staff told us 1 staff member was available 24 hours a day and then during the day a second staff member came in. They were unable to demonstrate to us how they then provided the assessed hours to people; there were not rotas or records in place to evidence this.

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.

There were processes in place to ensure staff protected people from the risk of cross infection. Staff confirmed Personal Protective Equipment (PPE) was available, and they had received training in this area. One staff member told us, “There is enough PPE”.

Medicines were not always managed in a safe way.

We saw medication administration records were handwritten. There was no evidence to confirm this information had been accurately transcribed from the prescriber’s instructions. For example, there was no second signature to show instructions had been checked by a second staff member and no audits were shared with us to show this information was being checked for accuracy. This increased the risk of people not receiving medicines in line with how it was prescribed, placing them at risk of harm.

When people had ‘as required’ medicines there was not always guidance in place for staff to follow. When people did have guidance, it lacked detail. For example, for 1 person who communicated nonverbally, the guidance referred to staff observing this person for pain. However, there was no information for staff to show how the person may present at this time or guidance to direct staff action. This placed people at an increased risk of not receiving the right medicines at the right time.

The records we viewed showed us people had received their medicines when needed and as prescribed.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.