The assessment began on 17 July 2024 and ended on 29 July 2024. Llyon Health is a domiciliary care agency providing personal care for people in their own home. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do, we also consider any wider social care provided. At the time of our assessment, the service supported 27 people, 13 of whom were supported with personal care. Improvements had been made since our last inspection and Llyon Health was no longer in breach of regulations. Staff were safely recruited and received the training and support for their role. People said staff were kind, attended all calls and stayed the full length of the call. A range of checks and audits were made, with actions identified where required. However, one local authority said the service did not always follow their procedures when people’s care hours changed, and some people had been charged for support calls they had previously cancelled. The registered manager had raised this themselves during the inspection and said they had improved the invoicing system.
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LlyonHealth received a focused inspection in May 2023 and remained Requires Improvement overall, with Well-led deteriorating to Inadequate due to continued breaches of regulations 17, 18, and 19 around governance, staffing, and recruitment. Critical failures included an unreported safeguarding incident involving falsified records, pre-populated supervision forms, unsafe recruitment practices, and a registered manager who was absent for both office visit days and failed to submit a required action plan.
Concerns (10)
criticalStaffing levels: “Staff continued to not be recruited safely, with gaps in employment histories and references not always being completed.”
criticalStaff training: “New members of staff did not always receive key training by the provider. The registered manager relied on previous training staff had completed with other care providers.”
criticalSafeguarding: “A staff member not attending a call, falsifying records, and not reporting a person's catheter being removed...had not been reported the local safeguarding team or CQC.”
criticalGovernance: “Audits completed had not always identified the concerns we found on inspection. There was an overreliance on office staff to complete a number of quality checks.”
criticalIncident learning: “The registered manager lacked awareness of their statutory responsibilities in relation to safeguarding statutory notifications to inform CQC of certain safeguarding incidents.”
moderateStaff competency: “There was no formal process for the provider to assess the effectiveness of the training staff had received to established if they had the necessary skills to care for people.”
moderateSupervision / appraisal: “We found many supervision forms had been pre-populated and not discussed with the individual staff member.”
moderateMedication management: “We reviewed MAR charts and found a number of gaps. The registered manager did not ensure these omissions were reviewed appropriately.”
moderateLeadership: “The registered manager was not available for the 2 days we visited their office...The provider failed to submit this action plan.”
moderateRecord keeping: “Information such as accidents, incidents and training information were not always readily available to view on site.”
Strengths
· Improvements had been made to call times and no missed calls were reported at this inspection.
· An electronic call monitoring system was introduced to improve oversight of staff scheduled visits.
· Medicines were generally managed safely and all staff administering medicines had received training and annual competency checks.
· People's care plans contained up to date risk assessments and management plans.
· Effective infection prevention and control procedures were in place including PPE use.
Quality-Statement breakdown (15)
safe: Staffing and call schedulingRequires improvement
safe: Fit and proper persons employed (Regulation 19)Requires improvement
safe: Using medicines safelyRequires improvement
safe: Learning lessons when things go wrong / safeguardingRequires improvement
safe: Assessing risk, safety monitoring and managementGood
safe: Preventing and controlling infectionGood
effective: Staff induction, training, skills and experience (Regulation 18)Requires improvement
effective: Assessing people's needs and delivering care in line with standardsGood
effective: Supporting people to eat and drink enoughGood
effective: Working with other agencies to provide consistent, effective careGood
effective: Ensuring consent to care and treatment in line with MCAGood
well-led: Governance, oversight and regulatory compliance (Regulation 17)Inadequate
well-led: Staff culture and workforce conditionsInadequate
well-led: Duty of candour and statutory notificationsInadequate
LlyonHealth was rated Requires Improvement following a focused inspection that identified breaches in safe care (medicines), fit and proper persons (recruitment), staffing (training and call scheduling) and good governance, the latter resulting in a Warning Notice. Safeguarding, risk assessment and infection control remained adequate, but quality assurance, oversight and staff competency systems required substantial improvement.
Concerns (11)
criticalMedication management: “one person had missed their medicines over a 24-hour period, due to staff not ordering a repeat prescription in time. As a result, the registered manager raised a safeguarding referral.”
criticalMissed or late visits: “The carers arrive at any time, I do not have a set time. In the morning they come as late as 10.00 or 11.15am, I am awake, but I have to wait for the carers to get me up and to get my breakfast and I am hungry.”
criticalStaff training: “The training matrix indicated staff had completed 20 e-learning courses in one day. This approach was not good practice and staff members retention of these courses would not be sufficient.”
criticalStaff competency: “The service did not have an effective system to check the care workers competency to ensure they were skilled and experienced to safely support people.”
criticalGovernance: “There was not a robust quality assurance process in place to monitor and drive improvement regarding areas such as recruitment, staffing, accidents and incidents or training.”
criticalGovernance: “Systems had not been established to assess, monitor and mitigate risks to the health, safety and welfare of people using the service and staff.”
criticalRecord keeping: “References from previous employers were not always sought and application forms didn't always record the staff members full employment history.”
criticalSafeguarding: “Recruitment systems were not in line with current legislation or the provider's policy to keep people safe from inappropriate staff working with them. This placed people at risk of potential abuse.”
moderateMedication management: “We identified missing signatures on one person's medicines administration records (MAR) over a number of months. There was no evidence provided to suggest the service had followed this up.”
moderateLeadership: “There were periods where the service lacked leadership or management oversight. The registered manager was also the director of the care agency.”
moderateIncident learning: “Systems and processes for accidents and incidents was not robust and could not be accessed when we visited the service due to a computer glitch.”
Strengths
· Systems and processes were in place to protect people from the risk of abuse and neglect; staff had received safeguarding training and knew the signs of abuse.
· People's care plans contained up to date risk assessments and management plans covering personal and health care needs.
· Effective infection prevention and control procedures were in place, including those relating to COVID-19.
· People's needs were assessed before the service began, with their views sought to inform personalised care plans.
· Staff received an induction aligned to the Care Certificate and could shadow more experienced staff.
Quality-Statement breakdown (16)
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: Assessing risk, safety monitoring and managementGood
safe: Preventing and controlling infectionGood
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the law
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Good
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies; supporting people to access healthcareGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
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: Duty of candour and continuous learning and improving careRequires improvement
well-led: Working in partnership with othersGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringRequires improvement