Lilycross Care Centre

Updated 26 November 2021

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection team consisted of two inspectors and a nurse specialist.

Service and service type

Lilycross Care Centre is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

The inspection was completed over three days. The first and the second day was unannounced. We gave a short period of notice ahead of the third day.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We used all of this information to plan our inspection.

During the inspection

We spoke with seven people who used the service and three relatives about their experience of the care provided. We spoke with eighteen members of staff including the provider, registered manager, deputy manager, senior care workers, care workers and the chef. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We reviewed a range of records. This included twelve people’s care records and multiple medication records. We looked at three staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records.

Updated 26 November 2021

About the service

Lilycross Care Centre is a care home providing personal and nursing care. The home was initially set up in response to the COVID-19 pandemic to provide care for people with a COVID-19 diagnosis. The home is currently providing short term respite care for people discharged from hospital.

Lilycross Care Centre accommodates 60 people across three separate floors, each of which has separate adapted facilities. There were 46 people living at the home at the time of the inspection.

People’s experience of using this service and what we found

Risk assessments were either not completed or not detailed enough to guide staff on how to safely support people with specific health conditions. People’s outcomes were not always reviewed. Risk was not always recognised in the environment and people had access to things that could harm them such as other people's medicines.

People received their medicines as prescribed. However, medicines administration records (MAR) were not always completed in line with best practice guidance.

Systems and processes to assess and monitor the safety and quality of the service were ineffective. The concerns found with care planning, risk assessments, environmental safety, and unsafe medicines practice were not identified by the registered managers or the provider’s monitoring processes.

Systems were not robust enough to ensure learning from incidents was implemented to further reduce risk to people.

Staff knew people well including their likes and dislikes however, not all care records reflected this level of detail.

Records were not of good enough quality to ensure the registered manager had effective oversight of areas such as staff training and medication competency assessments.

Systems and processes were in place to safeguard people from the risk of abuse and people told us they felt safe with staff. However, it was not always clear that lessons had been learnt from previous safeguarding investigations.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. Capacity assessments and best interest decision records were in place. However, records did not always demonstrate the relevant people were involved in the decision-making process.

Staff were safely recruited. Interactions we saw with staff and people were carried out in a caring and compassionate way. However, staff were very busy, and most interactions appeared to be task orientated.

Systems were in place to gather the views of people living at the home and staff. We saw examples where feedback was listened to and acted upon such as putting clocks in people’s bedrooms.

People spoke positively about the food. Comments included, “The food is fabulous, you get some great food here.”

The home had a good working relationship with local hospitals and worked hard to ensure people were discharged in a timely manner. The registered manager understood their duty to share information in an open and honest manner. They approached the inspection with transparency and worked hard to address the shortfalls we found during the inspection.

Rating at last inspection

This service was registered with us on 14/05/2020 and this is the first inspection.

Why we inspected

This was a planned inspection for this newly registered service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report.

The provider immediately responded to the concerns we raised and took swift action to improve the safety of the environment, the detail in people’s care records and governance processes.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to risk assessing and governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.