Lilyrose Care Group Ltd, Cambridge was rated Good overall, with Safe and Well-led both rated Good following a focused inspection of this small domiciliary care agency. Inspectors found safe medicines management, improved recruitment practice and a supportive manager, but noted mixed feedback on staff consistency, gaps in emergency-care guidance, incomplete induction records and a missed CQC notification.
Concerns (7)
moderateCare planning: “there was not always clear guidance for staff of when to call for emergency care”
moderateStaffing levels: “Continually firefighting due to shortage of staff and problems with recruitment.”
moderateStaff competency
: “[The service] has a high turnover of staff... but the new ones never stay long.”
moderateGovernance: “such an event had occurred since our last inspection, and not been reported to us”
minorInfection control: “two people told us staff were not always wearing masks correctly”
minorRecord keeping: “some staff induction records had not been fully completed”
minorStaff training: “Not trained properly to meet their family member's needs.”
Strengths
· Required recruitment checks completed prior to staff working for the service
· Medicines well managed by trained and competent staff with regular competency checks
· Effective infection prevention and control measures and PPE provision
· Safeguarding training in place; staff confident to report concerns internally and externally
· Manager acknowledged and responded when things went wrong; lessons shared with staff
Quality-Statement breakdown (10)
safe: Staffing and recruitmentNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Assessing risk, safety monitoring and managementNot rated
safe: Using medicines safelyNot rated
safe: Preventing and controlling infectionNot rated
safe: Learning lessons when things go wrongNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsNot rated
well-led: Engaging and involving people using the service, the public and staffNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated
well-led: Working in partnership with othersNot rated