Lilyrose Care Group Ltd - Cheshire/Derbyshire

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We assessed 4 quality statements in the well-led key question and found areas of good practice and concern. The scores for these areas have been combined with scores based on the rating from the last inspection, which was requires improvement. We identified one breach of the legal regulations. Governance and quality monitoring was not always effective in identifying and rectifying issues relating to people’s care. Audits and checks had not identified failing we found during the assessment period, relating to people’s risks, medicine, MCA, reporting of incidents to CQC and recruitment practices. The management team acknowledged the improvements requires in these areas and had taken actions to address some of the failings identified during the assessment. However, these had not been fully completed, or embedded into practice. The management team discussed challenging around staffing and the focus on safe staffing and ensure that care calls took place over that period, they were focused on making ongoing improvements. The deputy manager acknowledged experience gaps and further learning that was required to support their development, with the oversight of the registered manager. Overall staff were positive of the support from the management team and being always available when required. Supervisions took place with people and the deputy manager discussed ensuring that more regular teams meeting occur.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The management team were open and transparent during the assessment process, and shared some of the areas where they believed improvements were required. However, oversight systems had not identified all the issues we found during the assessment. During the assessment process, the deputy manager acknowledged they were new to the role and were learning about the service. They were addressing some of the team and systems issues. Overall feedback from staff was positive to the approach and support from the deputy manager and management team. Staff said the deputy manager was very responsive and had an open-door policy. There was an on-call rota and staff felt supported in that further guidance was always available should they require it. Comments included, “You can call the managers at any time, whenever you need something. They are supportive” and “There are no barriers to communication with the management, they are always available to give guidance. If I can't understand, I ask the manager. I've never observed that before. They are very responsive, they always guide.” The approach of the management team was caring. We observed examples where the management team and staff wished to work outside designated calls times to ensure that people and their loved one’s well-being was supported. The management team were aware of people and staff with protected characteristics. They gave an example how they have taken this into account to support a member of staff.

The registered manager was also the nominated individual and was not always based at the location. The day-to-day management was led by the deputy manager, who was responsive and had worked to address several issues highlighted during the assessment process. The deputy manager acknowledged their lack of experience in the role, and they were in the process of learning about aspects of the service and people’s needs. They were unfamiliar with some of the regulatory requirements relating to notifying CQC about certain events. During the assessment period it was evidenced that the management team needed guidance from the inspector around aspects of the role including approach to risk assessments, MCA and medicines records. We recommend the provider further considers the appropriate mentoring, support and training required by the management team in their new roles.

Staff told us they felt able to raise concerns and share feedback with the management team. However, we received some mixed feedback from staff that the management team addressed all issues raised. We saw evidence of occasional team meetings taking place. The deputy manager told us they intended for these to be more frequent in the future. They told us they encouraged staff to come into the office at any time. We observed staff visiting the office during our visits and contacting the management team by telephone for advice. Comments included, “She [the provider] listens and welcomes suggestions. She also arranges get togethers to relax. We talk about challenges, how we can improve, and she offers advice, that's fantastic.”

Staff we spoke to understood the whistleblowing policy and told us said they would have no hesitation in speaking with senior staff and the management team if they had concerns. Staff were given the opportunity to speak up and discuss any concerns. They felt comfortable speaking up and felt able to have open and honest discussions with the management team. This was evident in team meeting minutes shared by the registered manager, which recorded open conversation notes of staff concerns at the time the meeting took place.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The management team told us some audits, checks and reviews of people care records had not been completed due to the various issues they had experienced at the service with staffing and the previous registered manager leaving. The provider also said a regional member of staff used to carry out audits. However, we saw limited evidence of this, with no recent audits completed or available for us to review during the assessment period. Some senior staff told us they had not had the time to keep up to date with aspects of the team leader role including audits, as they were often attending to care calls and had limited time to spend in the office. The deputy manager told us they used ‘care planner’ for oversight of certain aspects of care, which alerted them when staff are due for spot checks, training, supervisions and appraisals. Some spot checks had been completed and the provider was in the process of undertaking any outstanding checks including medication competencies with staff. The deputy manager told us they were looking at current priorities to make improvements. IT systems were in place to monitor calls, training and staffing. They discussed that time was required to implement changes and embed these into practice.

Governance systems and processes were ineffective, which failed to identify shortfalls to monitor and improve the quality and safety of the service. The failure to operate effective systems resulted in a continued breach of regulation as well as a new breach being identified. Further shortfalls we found during the assessment related to medicines management processes, recruitment records, notifications of abuse to CQC, records relating to risk assessments and Mental Capacity Act assessment records for people. Provider checks to ensure quality assurance were not consistently completed. Therefore, there was no detailed overview of the quality and safety of the service and where improvements were required. The deputy manager shared that due to staffing shortfalls, care calls had taken priority to ensure people received their expected calls. A new system was being introduced to support improvements in these areas. Where senior leaders shared plans of improvements they intended to make, we found limited evidence of an action or development plan for staff to follow, or evidence when actions had been completed. Where some audits were carried out, aspects of auditing were behind due to staff needing to carry out care calls taking them away from this role. The registered manager was not based at the location but provided support. The deputy manager was supported by team leaders. A new care coordinator was recruited during the assessment period. The registered manager noted that a manager for another location was available to provide further support. The provider was introducing a new system to support a more streamlined approach to recruiting in the future. The current rating, certificate of insurance and registration information was on display at the office location and website. The provider had a business continuity plan.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Overall, staff and the management team felt the service was becoming more settled with changes in staffing and management. We received some positive feedback from people regarding staff support. People said staff were caring and treated them with dignity. People told us the service was generally responsive to any changes required or to feedback. Overall feedback from staff was positive regarding the support they received from the management team. They said the deputy was very responsive and had an open-door policy. Comments varied and included, “They ask if I have any suggestions, everything seems to be working well,” “Everything is good, I've learnt a lot” and “The [manager] is good at their job but doesn’t take on what you are saying.” The deputy manager told us there was a focus on improved communication through more regular meetings. However, we saw limited records of meetings or how feedback from staff was used to improve and develop the team or share lessons learned. The management team were open about improvements that were required and passionate about making the necessary changes. The deputy manager had already taken some actions to address some of the issues identified during the assessment period.

The provider had some oversight systems in place. However, these were not effective as they had not identified the issues we found during the assessment. Whilst some actions had been taken, the provider had not learnt and improved the service sufficiently following our previous inspection. The deputy manager carried out weekly calls to gather people's feedback and views about the service. However, we saw little recorded evidence about how people's feedback was actioned. People had been asked to complete quality surveys, which overall were positive. The provider agreed they needed to analyse and formalise responses into any lessons learnt in future. The provider had sent out questionnaires to staff but said they had received a limited response. Various systems were used to record information. The provider had plans to streamline and was introducing a new electronic care management system, which they felt would address some of the recording and organisational issues. The deputy told us they were focused on supporting staff with more regular meetings and supervisions moving forward. Supervisions identified developing best practice with the opportunity for a learning needs analysis. However, these were frequently recorded as undiscussed. The deputy manager had identified from feedback that more bespoke training would be of benefit to support some staff and was addressing this moving forward.