Background to this inspection
Updated
15 July 2022
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.
Inspection team
The inspection was carried out by one inspector and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.
Service and service type
This service is a domiciliary care agency. It provides personal care to people living in their own houses and flats.
Registered Manager
This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided. The registered manager left the service in 2019. The current manager was in the process of applying to register with us.
Notice of inspection
We gave a short period notice. This was because it is a small service and we needed to be sure that the provider or registered manager would be in the office to support the inspection.
Inspection activity started on 30 May 2022 and ended on 27 June 2022. We visited the location’s office on 23 June 2022.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used information gathered as part of monitoring activity that took place on 8 March 20222 to help us plan the inspection and inform our judgements. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.
During the inspection
During this inspection we spoke on the telephone with five people who use the service, six relatives, and six staff. These included three care workers, a senior care worker, a team leader, and the manager.
We also reviewed a range of records. These included sampling two person’s care records. We looked at two staff files in relation to recruitment and a variety of records relating to the management of the service. These included audits, records relating staff training, and meeting minutes.
After the inspection
We spoke with the nominated individual about the manager's registration with CQC.
Updated
15 July 2022
About the service
Lilyrose Care Group Ltd, Cambridge is a domiciliary care agency providing personal care to 12 people at the time of the inspection.
Not everyone who used the service received personal care. 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.
People’s experience of using this service and what we found
The provider had systems in place that helped ensure that staff delivered a service that met people's needs and kept them safe.
People felt safe receiving the service and were protected from avoidable harm by a staff team trained and confident to recognise and report any concerns. Medicines were well managed by trained and competent staff. The service used effective infection, prevention and control measures to keep people safe, and staff supported people to follow them.
People and relatives had mixed views about how well the service was managed. Some people and relatives made very positive comments about the service, the manager and how they were listened to. However, we also received feedback the service had been short-staffed, and improvements had not always been sustained.
The service had enough staff to meet people’s needs effectively. Senior staff regularly checked staff member’s performance and requested feedback from people. Where possible, they acted on people’s feedback and addressed their concerns. Most people gave very positive feedback about the staff who supported them. One person said, “The [staff] take their responsibilities seriously; they have a lot of energy, are kind and compassionate.”
There was effective communication in place to ensure staff were kept up to date with any changes in the service provided. Staff liked working for the service and felt valued. The manager led by example to create a positive and caring culture. Staff felt very well supported and made positive comments about them.
The registered manager left the service in 2019. The current manager was in the process of applying to register with us.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (report published 2 March 2020)
At our last inspection we recommended that the provider consider current legislation on recruitment requirements and take action to update their practice for further prospective employees. At this inspection we found they had made this improvement.
Why we inspected
We undertook this inspection as part of a random selection of services which have had a recent Direct Monitoring Approach (DMA) assessment where no further action was needed to seek assurance about this decision and to identify learning about the DMA process.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.