Lily Health Care Limited received an overall rating of Requires Improvement following a focused inspection of the Safe and Well-Led domains, with regulatory breaches identified under Regulation 12 (Safe Care and Treatment) and Regulation 17 (Good Governance) due to inadequate risk assessment, poor incident recording, medication record gaps, and ineffective quality auditing. Despite these governance failures, people and relatives expressed high satisfaction with care staff, safeguarding practices were sound, and the registered manager demonstrated openness and took immediate remedial action during the inspection.
Concerns (7)
criticalCare planning: “Risk assessments did not always contain detailed information about people's risks... actions staff should take to minimise these risks were not always detailed.”
criticalGovernance
: “The provider did not have effective systems and processes to ensure effective oversight of the service was maintained. Breach of regulation 17.”
moderateIncident learning: “Accident and incidents had not always been recorded since our last inspection to demonstrate what action had been taken to reduce risks for people.”
moderateMedication management: “We found gaps in 1 person's records, which had not been explored, and handwritten medication records had not always been signed by the staff member.”
moderateStaff training: “Some staff had not received training in relation to some of the medical conditions of the people they supported. For example, spinal injury, and stroke.”
moderateRecord keeping: “Late and missed calls were not recorded, and there were no systems to monitor when staff arrived and left their care calls.”
moderateStaffing levels: “Where staff had commenced employment and shadowing experienced staff before the return of their DBS check, a risk assessment had not been undertaken.”
Strengths
· Staff understood how to protect people from poor care and abuse, with training on recognising and reporting abuse applied effectively.
· People were supported to have maximum choice and control; staff worked within the principles of the MCA and sought consent before every interaction.
· Staff protected and respected people's privacy and dignity, promoting equality, diversity and culturally appropriate care.
· Registered manager was open, transparent and receptive to feedback, taking immediate action to address shortfalls identified during inspection.
· People and relatives spoke highly of care staff, describing them as 'absolutely brilliant' and 'amazing'.
Quality-Statement breakdown (12)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Using medicines safelyRequires improvement
safe: Learning lessons when things go wrongRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
well-led: Managers and staff being clear about their roles and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Engaging and involving people using the service, the public and staffRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candourGood
well-led: Continuous learning and improving careRequires improvement