Lily House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service is spread over two floors with access to the upper floors via a passenger lift.

At the last inspection in March 2016, the service was rated 'Good'. At this inspection we found the evidence continued to support the rating of good and there was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

Why the service is good.

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There was a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People were supported to remain safe. Risks to people were assessed, and any risks identified were mitigated and reduced where possible. There were sufficient numbers of staff with the right skills and abilities to support people when they needed it.

Staff continued to receive appropriate training and support to enable them to carry out their roles effectively. Medicines continued to be well managed.

Staff were aware of the Mental Capacity Act 2005 (MCA) principles and were meeting the requirements of the Deprivation of Liberty Safeguards (DoLS). People were encouraged and supported to make choices and retain as much control of their lives as possible. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People were supported to eat and drink sufficient amounts to maintain their health and were supported to access health care professionals to meet their individual health needs.

People who used the service were treated in a kind and caring way by staff who respected their privacy and maintained their dignity.

People, their relatives and professionals were given the opportunity to give feedback on the service and their views and opinions were taken into account.

People received individualised care that was personal to them. People were given appropriate support and encouragement to access activities that were of interest to them.

People and their relatives knew how to raise concerns if they needed to and were confident these would be listened and any concerns would be addressed.

The registered manager had quality assurance systems in place and where shortfalls were identified they were promptly acted upon to improve the service.

The registered manager had developed an open, transparent and inclusive culture within the service. People and their relatives gave positive feedback about all aspects of the service.

Further information is in the detailed findings below

Lily House is registered to provide accommodation and personal care for up to 44 people, some of whom live with dementia. The home is located in a residential area on the outskirts of the city of Ely. When we visited there were 31 people living at the home.

The inspection took place on 5 April 2016 and was unannounced. The last unannounced comprehensive inspection was carried out on 21 April 2015 when the provider was not meeting regulations associated with application of the Mental Capacity Act 2005 [MCA] and quality assurance of the home.

A registered manager was in post when we inspected the home and had been registered since 8 September 2015. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager was not managing the home when we inspected; interim management arrangements were in place pending the return of the registered manager from leave.

People were safe living at the home as staff were knowledgeable about reporting any abuse. There were a sufficient number of staff employed and recruitment procedures ensured that only suitable staff were employed. Arrangements were in place to ensure that people were protected with the safe management of their medicines.

The CQC is required by law to monitor MCA and the Deprivation of Liberty Safeguards [DoLS] and to report on what we find. The provider was acting in accordance with the requirements of the MCA so that people had their rights protected by the law. Assessments were in place to determine if people had the capacity to make decisions in relation to their care. When people were assessed to lack capacity, their care was provided in their best interests. In addition, the provider had notified the responsible authorities when some of the people had restrictions imposed on them for safety reasons. The provider was waiting to hear the results of the actions that these authorities may be taking.

Staff were trained to do their job and demonstrated how their training was applied to their practice. Staff supported each other but felt that, due to the interim management arrangements, they felt less supported by the current leadership arrangements of the home. The provider was aware of this concern and was taking action to address this.

People were supported to access a range of health care professionals. Health risk assessments were in place to ensure that people were supported to maintain their health. People were provided with adequate amounts of food and drink to meet their individual likes and nutritional and hydration needs.

People’s privacy and dignity were respected and their care was provided in a caring and attentive way.

People’s hobbies and interests had been identified and a range of activities supported people with these. People’s care records and risk assessments were kept up-to-date. A complaints procedure was in place and this was followed by staff. However, people and visitors were unclear who they could raise their concerns with but said that they had no complaints to make.

The provider had quality assurance processes and procedures in place to improve, if needed, the quality and safety of people’s support and care. Improvements were made in relation to recruitment of permanent staff; the environment and auditing of people’s care records.

We carried out an unannounced comprehensive inspection of this service on 21 April 2015. After that inspection we received concerns in relation to the safety and quality of people’s care. As a result we undertook a focused unannounced inspection to look into those concerns. This report only covers our findings in relation to those topics. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link Lily House on our website at www.cqc.org.uk

Lily House is registered to provide accommodation and personal care for up to 44 people, some of whom live with dementia. Nursing care is not directly provided as this is provided by the community nursing services. The home is situated in a residential area on the outskirts of the city of Ely. At the time of our inspection there were 37 people living at the home.

A registered manager was in post at the time of our visit. She had been in post since 30 September 2014 and on 8 September 2015 we made the decision to register her. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We received concerns that there were insufficient numbers of staff to meet people’s individual needs. During our inspection people were supported by a sufficient number of staff to enable people to take their medicines at the prescribed times. In addition, since our last inspection staffing numbers had increased and this enabled staff to supervise and observe people who were at risk of falls. This had reduced the number of incidents that required people to receive medical attention as a result of falling.

We received concerns that people did not live in a clean home and were at risk of acquiring preventable infections. During our inspection the home was clean and there were infection control procedures in place that staff followed. In addition, improvements had made in relation to the standard of the cleanliness and storage and handling of food in the kitchen.

Before the inspection we received concerns that people were not receiving care to reduce their risk of getting infections and that they were not given enough to eat and drink. People were supported to eat and drink sufficient amounts and records of these were monitored each day. Actions were taken to reduce the risk of people getting infections due to them taking sufficient quantities of drink. People’s weights were closely monitored and action was taken in response to people’s unintentional weight loss. This included the provision of fortified foods and referrals were made to a community nutritionist/dietician for their advice.

We received concerns that people’s mental health needs were not being met and this was due to lack of staff training and awareness of how to care for people living with dementia. Arrangements were in place for staff to attend training in dementia care. Staff were knowledgeable in how to manage people’s behaviours that challenged. The improvements had made people settled and they had gained benefits to their physical and emotional well-being.

Before our inspection we received concerns that people’s rights to privacy and dignity were not consistently respected. During our inspection people were being looked after in a respectful way by members of staff who were patient and kind. People also had their personal care provided behind closed doors.

We received concerns that the morale of staff was low and this was in relation to the lack of supervision and support of the team of staff. Improvements had been made to supervise and manage staff who were now aware of their roles and responsibilities and who worked as a team. In addition, the provider had carried out an improved system to monitor and take action to improve the quality and safety of people’s care.

Lily House is registered to provide accommodation and non-nursing care for up to 44 people, some of whom live with dementia. The home is located in a residential area on the outskirts of the city of Ely. When we visited there were 41 people living at the home.

The inspection took place on 21 April 2015 and was unannounced. The last inspection was carried out on 06 May 2014 when the provider had met the regulations that we inspected against.

A registered manager was not in post when we inspected the home. An application to register the manager was in progress. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People were safe living at the home as staff were knowledgeable about reporting any abuse. There were a sufficient number of staff employed and recruitment procedures ensured that only suitable staff were employed. Arrangements were in place to ensure that people were protected with the safe management of their medicines.

The CQC is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) Deprivation of Liberty Safeguards (DoLS) and to report on what we find. DoLS applications had been made to ensure that people’s rights were protected. However, there were inadequate assessments in place to assess people’s capacity to make decisions about their care and to justify why DoLS applications had been made. Staff were supported and trained to do their job.

People were supported to access a range of health care professionals. Health risk assessments were in place to ensure that people were supported to maintain their health. People were provided with adequate amounts of food and drink to meet their individual likes and nutritional and hydration needs.

People’s privacy and dignity were respected and their care was provided in a caring and attentive way.

People’s hobbies and interests had been identified and a range of activities supported people with these. Some people’s care records and risk assessments were not kept up-to-date. A complaints procedure was in place and this was followed by staff. People could raise concerns with the staff at any time.

The provider had quality assurance processes and procedures in place to improve, if needed, the quality and safety of people’s support and care. However, these had failed to ensure that people’s mental capacity had been assessed in line with the MCA. In addition, some of the people’s risk assessments and care records were not reviewed in the time that they should have been.

A staff training and development programme was in place and procedures were in place to review the standard of staff members’ work performance.

We found a number of breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014. You can see what action we have told the provider to take at the back of the full version of this report.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask;

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well led?

Below is a summary of what we found. It is based on our observations during the inspection, speaking with people who used the service; the staff supporting them and from looking at a range of records.

SAFE

We found that people’s medicines were managed well by staff, ensuring they received them as prescribed. People were also protected from the risk of infection because the home was kept clean and hygienic.

Potential risks to people had been identified and recorded clearly in their plans of care. We saw that these risks had been reviewed regularly to ensure that people were kept safe.

We found that there were enough staff on duty to meet people’s needs; however the home had been relying on agency staff recently to cover a number of staff shortages. One person told us that he found the use of agency staff unsettling and that he sometimes didn’t understand them if their first language wasn’t English.

Although staff had received recent training in the Mental Capacity Act, we found their knowledge of its practical application was limited and they were unable to identify when a person might need safeguards in place to protect their liberty.

CARING

We received many positive comments about the caring nature of the staff from people we spoke with during our inspection and the relatives we rang afterwards. One person told us, “I am constantly surprised by the staff’s patience; they never lose their tempers and have to deal with difficult people in here”. One family member reported, “They treat my sister with tenderness and concern, that’s the important thing as far as I’m concerned”.

We noted that people looked well cared for, were dressed appropriately and showed good signs of emotional well-being. Staff treated people respectfully and with dignity throughout our visit.

EFFECTIVE

We found that people’s health and well-being had been closely monitored and that they received good support both from the staff team and from a range of external health care professionals. One diabetic nurse specialist described staff’s management of people’s diabetes as ‘exceptional’.

RESPONSIVE

We noted many aspects of the home’s environment that were responsive to the needs of people with dementia. There was dementia friendly signage throughout the home to help people identify their bedroom and key locations such as toilets and bathrooms. Corridor walls were decorated with reminiscence objects to create an interesting and stimulating environment for people. Bedroom and bathroom doors had been designed so that they could be opened easily if someone fell against them. Information about daily activities in the home were in pictorial format to help people understand the information.

Family members we spoke told us that the staff and manager responded appropriately to their concerns.

WELL LED

Health care professionals we spoke had confidence in the manager and felt she had brought about good changes in the home in the last six month. One GP stated, “Sam has had a good impact on the home, she’s certainly been supporting and training staff and the home feels a lot more settled now”. However we did have concerns about staff morale in the home, with some staff telling us they did not feel well supported by the management team. They also told us about the high use of agency staff which sometimes hindered their everyday working practices. A recent staff satisfaction showed that of 10 respondents, only two felt their morale was good, and only one felt they knew what was going on within the company.

Systems were in place to monitor the service people received, and these had been effective in identifying shortfalls.

During our inspection we looked at how people were cared for and how staff supported people living with dementia. We spoke with the deputy manager, the compliance officer supporting the service, three staff members and five people who used the service living with dementia. We also received two comment cards from relatives of people who used the service. All the comments we received were complimentary about the service and its staff.

We found that staff were caring and attentive to people's needs. We saw that people had enough to eat and had access to snacks throughout the day. We saw that the service arranged activities such as reminiscence and memory games and the service confirmed that they were signed up to the dementia pledge at the time of our inspection.

We saw that the service had effective working relationships with other providers and accessed other professionals to support people when this was required. The deputy manager told us that in general the hospitals worked well with them to support people who were being admitted or being discharged.

We saw that the service had effective quality assurance processes in place to monitor the dementia care people received.

As this inspection was to assess improvements made in relation to shortfalls identified during our previous inspection on 09 September 2013, we did not request information directly from people using the service on this occasion.

Overall, we found that the provider had taken sufficient action to ensure that people's care and welfare needs were met.

We observed how staff members interacted with people using the service and found that staff members were gentle, congenial and listened to people.

We examined records for information regarding decisions made in line with the Mental Capacity Act. Care records contained details of decisions people were not able to make for themselves.

We found that although improvements had been made to the care plans not all of them contained the information that staff required to meet their needs.

People were provided with a choice of suitable and nutritious food and drink. We observed the lunchtime and found that people were supported to eat and drink when needed.

We found that appropriate arrangements were in place in relation to the administration and recording of medicine.

Staff members confirmed that they felt staffing levels were adequate and this allowed them to provide care and support to people.

During our inspection on the 27 June 2013 we found that staff did not always treat people respectfully but that there were some positive interactions between the staff and people who lived in the home. One person told us "The staff are always polite". Another person told us, " Most staff are caring, some can be a bit sharp when they're in a hurry".

We found that the care plans did not always reflect people's current needs or give the staff all of the information they required to support the person adequately . The area manager had already identified that improvements were needed to be made and had booked further training for staff to attend to enable them to improve their assessments and care planning.

Although all of the people we talked to told us they were happy with the food, we found that people didn't always get the support they needed to ensure that they had adequate food and drink.

We found that due to inappropriate recording and storage of medication we could not be sure that people had always been given their medication as prescribed. Although the home had completed regular medication audits they had failed to highlight that improvements were needed.

People told us that the staff were normally polite and helped them when needed. The staff told us that they got people ready for bed early as there was not enough time after tea to help people.

People told us if they were unhappy with anything they would talk to a member of staff or the manager.

At the time of our last inspection, on 27 June 2012, we had concerns about the recruitment procedure and the lack of staff understanding of safeguarding issues. This inspection, on 30 November 2012, was carried out to check that the necessary improvements had been made.

At the time of the last inspection the manager had been seconded to another home owned by the provider. She had returned to Lily House by the time we carried out this inspection. We spoke with the manager, with staff and looked at records. We found that the necessary improvements had been made. For example, staff had received additional training with regard to safeguarding vulnerable adults from abuse. Staff that we spoke with demonstrated they had a good understanding of the correct procedure to follow if concerned about abuse. A new recruitment procedure had been implemented and we saw evidence that this was being followed to ensure that correct checks were carried out prior to staff starting work at the home.

People who we talked with told us they liked living in the home and that the staff helped them when they needed their support. The relative of one person living in the home told us that the staff were wonderful and that if she had any concerns she would talk to the manager about them straight away.