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 requires improvement. At this assessment the rating has changed to good.

This meant people were safe and protected from avoidable harm.

This service scored 69 (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 learnt to continually identify and embed good practice. Improvements had been made since our last inspection, and the registered manager was more proactive at ensuring lessons were learnt. They had developed an action plan since our last inspection which they worked through to ensure the concerns we identified had been met and actioned. We saw the information considered learning for the future and measures to try to mitigate future risks.

There were systems in place to ensure lessons were learnt to ensure good practice was continued and staff were aware of where learning had been identified and felt involved with this process.

The provider made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

There was a process in place to ensure people’s needs were assessed, reviewed and considered before they started using the service. The assessments we saw considered people’s risks, needs, likes and dislikes. People and those important to them were involved with this.

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

There were systems in place to ensure safeguarding concerns were identified, reviewed and investigated. 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.

Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We saw people were comfortable in their environment.

There was a system in place to ensure people had care plans and risk assessments that had been developed individually, based on their assessed needs, which were reviewed when needed. Plans considered people’s levels of support, mobility needs and known risks.

Where improvements were needed to ensure people had suitable risk assessments and care plans in place, we saw these changes had been made. Where we had previously identified concerns, the provider had made changes to people’s safety, this included reviewing the needs of a person who used a mobility aid. These plans were reviewed regularly or when changes had occurred.

The provider did not always detect, control or escalate potential risks in the care environment.

Care records showed us people who resided in 1 of the supported living locations, liked to access the garden area of their home. However the garden area was cluttered, with areas in need of repair and no seating available to enable people with mobility needs to use these areas safely. We shared our findings with the registered manager who told us they had taken action to resolve this and make improvements. However, we provided this same feedback at our last inspection, which showed the environmental risks had not been appropriately escalated in a timely manner. We will review progress with this at our next inspection.

People had individual risk assessments in place that related to their environment. This information was available for staff, so they were aware of any risks that maybe present.

The provider had systems in place to ensure there were enough staff available to support people.

People and relatives raised no concerns with the number of staff available to support people. We saw care was delivered to people based on their assessed needs. The registered manager had ensured it was clearer how people’s individual hours were planned for and delivered.

Staff had received training to ensure they had the relevant knowledge and skills to support people. This included training which was specific to people needs including epilepsy training. Staff spoke positively about the training they received. One staff member said, “We have had to redo some training, it has helped us”.

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.

Medicines were not always stored securely. Improvements had been made to how medicines were individually stored for people, these had considered people’s individual needs and preferences. For example, 1 person’s medicines were now stored in a lockable cupboard in their bedroom. There were risk assessments in place for these changes. However, the keys to people’s individual medicines were not safely stored by staff. We also found 1 person’s liquid medicine was stored in a fridge that all people and staff had access to. This meant there was a risk that medicines could be accessed or tampered with by people which may cause them or others harm.

Medicines administration records (MAR) were no longer routinely handwritten. However, when people had additional medicines introduced, these were added to the MAR charts by staff and there was not always 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. This increased the risk of people not receiving medicines in line with how they were prescribed, placing them at risk of harm.

We shared our concerns with the registered manager who took immediate action to resolve the concerns we raised, we will review this as part of our next inspection.

However, people and relatives raised no concerns with how medicines were administered. People received their medicines as prescribed. When people had ‘as required’ medicines there was guidance in place for staff to follow. Staff administering medicines had received training and their competency was checked to ensure they were safe to administer these to people.