Lilac Cottage

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last inspection we rated this key question requires improvement. At this inspection the rating has improved to good. This meant people were safe and protected from avoidable harm.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. There was an incident and accident log in place which was audited every month for patterns and trends. Any learning was identified and discussed during staff team meetings.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. People were supported using an initial assessment and matching process before they moved to Lilac Cottage. In instances where some people had chosen to move to another service or their own home, this was done safely with the registered manager supporting them.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives, while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately. All safeguarding concerns had been reported appropriately. Staff told us they knew how to report concerns. One staff member said, “I would report this to the manager, or phone safeguarding myself.” There was accessible information for people so they could understand safeguarding and how to report concerns. Where appropriate, DoLs (Deprivation of Liberty Safeguards) had been applied for and any conditions on people’s DoLs were being routinely checked.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. There were comprehensive risk assessments in place which clearly describe the course of action to take if people were at risk of harm. Risk assessments were reviewed when needed or following an incident, and there was a strong focus on learning lessons. People told us they felt safe. One person said, “I would always tell the staff if I didn’t (feel safe).”

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. People were supported to keep their flats clean and tidy. All communal areas were clean and well maintained and there was a schedule of health and safety testing, and checks carried out at the home.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. A staff member told us, “We are a very close-knit team. We do not use agency because it’s nice to make sure people have consistent support.” Staff were safely recruited and had undergone specific training to enable them to support people in accordance with their assessed needs.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. There were dedicated areas for the storage of cleaning products. People cleaned their own flats with support from staff, and infection control audits had been completed monthly to ensure compliance.

The service made sure medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened. Documentation relating to medicines were up to date and reviewed as people’s needs changed. For example, we saw one person had been reviewed by their GP and was prescribed a different medication. This was added to their medication administration record (MAR) and their care plan was updated. Only staff who had undertaken medication training were permitted to administer medicines. The service worked within the guidelines of STOMP [Stopping over medication of people with a learning disability and autistic people] to ensure people were being given PRN medication (which is medication needed as and when required) appropriately.