CQC report explained · a residential care home
What the CQC found at The Lilacs Residential Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, September 2022
The Lilacs Residential Home is rated Requires Improvement; inspectors found kind, personalised care, but medicines were not always managed safely and oversight needed to improve.
This was an unannounced inspection on 15 August 2022 by two inspectors. They spoke with people, a relative, staff and a healthcare professional. They observed care and checked care plans, medicines records, staff recruitment files and management records.
People were generally happy and said staff were kind and respectful. Inspectors found good care planning, enough staff, suitable training, support with food and healthcare, and activities. The home had also made environmental improvements since a new provider and management team took over.
There were important problems with medicines. Records had gaps, one person's tablets appeared to have been signed for but not given, and some medicines were missing from records. The systems used to check quality had not found these problems. The overall rating and the Safe and Well-led ratings are Requires Improvement, while Effective, Caring and Responsive are Good.
Kind and respectful care
People described staff positively, and inspectors saw relaxed and friendly interactions. Staff understood people's wishes and supported their dignity and independence.
“Staff promoted people's independence and protected their privacy and dignity.” from the report
Personalised care plans
Care plans contained the information staff needed to support people safely. People and, where appropriate, relatives were involved in planning care.
“Care plans were detailed and contained all the information staff needed to support people.” from the report
Staffing and training
Inspectors found suitable staffing levels and regular staff who knew people well. Recruitment checks, induction and training were in place.
“Staff were supported by regular staff who knew them well.” from the report
Food and healthcare support
People were supported to eat and drink enough, including when the weather was hot. The home worked with GPs, nurses and other health professionals.
“People were supported to have enough to eat and drink.” from the report
Medicines were not always safe
seriousMedication records had gaps and did not always show that people received medicines as prescribed. Inspectors also found tablets that appeared to have been signed for but not given.
“We reviewed medication administration records (MARs) and found gaps in recording. This meant we could not be assured people had received their medicines as prescribed.” from the report
Quality checks missed problems
needs fixingThe manager did not have full oversight, and medicine audits had not found the issues identified by inspectors. The provider said systems would be reviewed.
“The registered manager did not have full oversight of the service.” from the report
- 01What changes have been made to prevent gaps in medication administration records?
- 02How do you now check that medicines, including as-required medicines, are recorded and given correctly?
- 03How are medicine audits reviewed to make sure they identify problems promptly?
- 04What further training has staff received on the electronic care planning system?
- 05What improvements from the refurbishment plan have been completed, and what remains to be done?
This was an unannounced first inspection of the newly registered service, covering all five key questions and infection prevention and control; the previous Good rating was under the former provider. This explanation was written from the published report of 3 September 2022 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, February 2022
Inspected but not rated; inspectors found good infection control and safe visiting arrangements during the pandemic.
This was a targeted inspection on 25 January 2022. It looked at infection prevention and control, visiting arrangements and staffing pressures linked to COVID-19. The visit was announced one day beforehand.
Inspectors found good practice. The home had systems for testing people and staff, using personal protective equipment, managing possible outbreaks and supporting safe visits. Staff had been trained to use protective equipment correctly.
People continued to receive healthcare, including visits from a GP practice nurse. Staff checked people's temperatures daily and monitored oxygen levels when people appeared unwell. The home was inspected but not rated, so this report does not give a new overall quality rating.
Infection control
The home had systems to prevent and manage infections, including updated policies, hygiene measures and outbreak planning.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
PPE and testing
Staff had training in using PPE, and people and staff were regularly tested for COVID-19.
“All staff had received training on how to properly use PPE and there were good systems set up in the service to support the donning and doffing of PPE.” from the report
Safe visiting
The home had arrangements to support visits safely, with video and telephone calls used when visits could not take place.
“Guidance had been implemented to allow where possible, for relatives to continue to visit people safely.” from the report
Access to healthcare
People continued to receive healthcare support, while staff monitored their health and shared information with other professionals when needed.
“People had been supported to continue to access healthcare, this had included visits from the GP practice nurse.” from the report
Inspectors raised no specific concerns in this report.
- 01How are staffing pressures affecting the home now, and what measures are in place if staffing levels fall?
- 02How are visits arranged now, and what happens when an in-person visit cannot go ahead?
- 03How does the home prevent and manage infection outbreaks?
- 04How are people tested and supported if they show signs of illness?
- 05How does the home arrange GP and other healthcare appointments for residents?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19-related staffing pressures; it did not provide ratings for the other areas of care. This explanation was written from the published report of 1 February 2022 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 The Lilacs Residential Home
4 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- September 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2022Inspected but not ratedSafe: Inspected but not rated
- November 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2017Goodstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2021
Registered with the Care Quality Commission on 1 June 2021.
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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