Archived: Lilycross Care Centre

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.

We found the following examples of good practice

• The service followed good infection prevention control standards. Training, policies, procedures and equipment were in place to maintain infection control and support the needs of the people using the service.

• A safe visiting procedure was in place and followed. Visitors to the service had their temperature taken and competed a health screening questionnaire. Hand sanitiser was available, and a PPE station and changing facilities were located near to the main reception. The reception area was enclosed and regularly sanitised.

• The service had a separate area with a designated staff team to support people with COVID-19.

• The service was registered for regular testing to ensure people and staff were tested frequently, even if they did not present with symptoms. This helped to minimise any spread of infection.

• Risk assessments specific to COVID-19 had been devised with input from the local infection control team, meaning that they were up to date and effective at minimising risks of infection to people.

Further information is in the detailed findings below.