CQC report explained · a residential care home
What the CQC found at Lilac Cottage
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, January 2020
Requires Improvement; inspectors found improving leadership and kind care, but concerns about safety records, staffing and missed notifications.
This was a focused inspection after concerns about safety, staffing and management. Inspectors visited on 13 and 27 December 2019, spoke with people, relatives and staff, observed care, and checked care, medicine, recruitment and management records.
The home had been unsettled while its registered manager was working elsewhere. Inspectors found that management oversight had not always been effective. Risk assessments and care records were not always complete or up to date, staffing had been unreliable, and some safeguarding events had not been reported to the CQC.
There were also positive signs. People generally felt safe, medicines were supported safely, the home was clean, and relatives spoke positively about the care. The registered manager had returned full-time and had started improving records, staffing and management checks.
The overall rating changed from Good to Requires Improvement. Safe was rated Requires Improvement, and Well-led remained Requires Improvement. The other three areas were not inspected during this visit, so their previous ratings were carried forward.
People generally felt safe
People generally said they felt safe, and some relatives said their family members were safe and well looked after.
“Overall, people told us they felt safe living at Lilac Cottage” from the report
Safe medicines support
Staff supported people to take medicines safely and encouraged them to be as independent as possible.
“Staff supported people with their medicines safely. Staff helped people to take their medicines as independently as possible.” from the report
Positive management changes
The registered manager had returned full-time and was taking action to improve records, staffing and oversight.
“Between the two days of our visit, the registered manager had already acted to improve records and rectify issues.” from the report
Kind relationships
People and relatives gave positive feedback about staff, the atmosphere and support with family relationships and activities.
“I am happy here, the staff are nice. We [people who live here] get together, watch movies and have meals together.” from the report
Safeguarding events were not reported
seriousThe CQC was not told about some events involving abuse or allegations of abuse. This was a breach of the registration regulations.
“The Care Quality Commission (CQC) had not been notified of some specific events regarding abuse or allegation thereof in line with legal obligations.” from the report
Risk records were not consistently current
needs fixingSome risk assessments were incomplete or had not been regularly updated. A few staff also still needed training linked to people's safety plans.
“However, at times information in these assessments had not been fully completed or updated through regular review.” from the report
Staffing had been unreliable
needs fixingPeople and relatives gave mixed feedback about whether there were enough staff. The home was recruiting and staff said reliability was improving.
“Some staff have left, others are not always turning in.” from the report
Records and oversight needed improvement
needs fixingPerson-centred records were not always up to date, and audit actions were not always completed effectively. Partnership working with people, families and other professionals also needed to be more robust.
“Records needed to be reviewed and completed more effectively, to ensure person-centred information was up to date.” from the report
- 01How do you now make sure safeguarding incidents and allegations are reported to the CQC without delay?
- 02How often are each person's risk assessments reviewed, and who checks that they are complete and up to date?
- 03What are the current staffing levels on each shift, and how do you cover unexpected absences?
- 04Which staff still need training linked to people's safety plans, and when will this be completed?
- 05What changes have been made to records, audits and partnership working since this inspection?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 24 January 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, March 2019
Lilac Cottage was rated Good overall; inspectors found kind, person-centred care, but records and quality checks needed improvement.
This was an unannounced, planned inspection on 14 and 15 March 2019. One inspector reviewed care records, medicines, staffing, training, incidents, audits and complaints. They also observed care and spoke with people and staff.
People told inspectors they felt safe and were happy with their care. Staff supported people to make choices, build independence and take part in community activities. Inspectors found enough staff, kind relationships, good access to healthcare and suitable support with food and medicines.
The overall rating remained Good. Safe, Effective, Caring and Responsive were all rated Good. Well-led fell to Requires Improvement because some controlled-drug records, risk information and care plans were not clear or reliable enough. The report made a recommendation about improving records and governance.
Person-centred support
Care focused on people's choices, outcomes and independence. Inspectors saw examples of people developing skills and moving towards supported living.
“Support was clearly focussed on good outcomes for people and promoting independence.” from the report
Kind relationships
Inspectors observed warm interactions and people said they felt at ease with staff.
“We observed warm and caring interactions between people who lived at the service and staff.” from the report
Community involvement
People were supported to take part in activities that mattered to them, including work in charity shops and trips.
“People accessed the community for a variety of activities that were important to them and to promote their recognition as a valued citizen of their wider community.” from the report
Good complaints arrangements
People knew how to raise concerns. The complaints process was displayed and available in different formats.
“People felt that staff listened to them and that their complaints were always resolved, if they had any.” from the report
Controlled-drug records
needs fixingInspectors found mistakes in the recorded stock amounts for controlled drugs and related care-plan information was missing. The medicine had been given correctly and the stock was correct, but the records were not reliable.
“Aspects of record keeping regarding controlled drugs needed to improve.” from the report
Risk and intervention guidance
needs fixingSome care plans and risk assessments did not link clearly enough. Guidance about incidents and more restrictive physical interventions needed to be clearer and more consistent.
“Information relating to risk management processes in care plans needed to be clearer and more consistent.” from the report
Additional staff learning
minorMandatory training was generally good, but few staff had completed some additional learning about mental health and other important needs.
“Few staff had completed the additional learning sessions and this needed to be improved.” from the report
- 01How have you improved the recording and checking of controlled drugs since this inspection?
- 02How do you make sure care plans and risk assessments give staff consistent guidance about incidents and physical interventions?
- 03How do you monitor the use of physical interventions and make sure the least restrictive approach is used?
- 04How many staff have now completed the additional learning about mental health and people's specific needs?
- 05What arrangements are in place if there is a fault affecting heating or hot water?
This was an unannounced planned inspection covering all five CQC questions; the overall rating had been Good at the previous inspection. This explanation was written from the published report of 29 March 2019 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Lilac Cottage
3 rated inspections over 3 years: the service has slipped, from Good to Requires improvement.
- January 2020Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2019Goodstayed GoodSafe: GoodWell-led: Requires improvement
- September 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2015Insufficient evidence to rateSafe: Insufficient evidence to rateEffective: Insufficient evidence to rateCaring: Insufficient evidence to rateResponsive: Insufficient evidence to rateWell-led: Insufficient evidence to rate
- May 2015
Registered with the Care Quality Commission on 19 May 2015.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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