The inspection took place on 21 December 2017 and was announced.

This service is a domiciliary care agency. It provides personal care to people living in their own houses and flats in the community. It provides a service to adults of all ages, some of who may be living with a physical disability or dementia.

Not everyone using Lily Mae receives regulated activity; CQC only inspects the service being received by people provided with ‘personal care’; help with tasks related to personal hygiene and eating. Where they do we also take into account any wider social care provided.

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.

This was the services first inspection since their registration with the Care Quality Commission.

The provider was not meeting the legal requirements in relation to managing people’s medicines safely and completing the appropriate checks to ensure that staff were safe to work with people using the service before they started work. You can see the actions we have asked the provider to take at the back of this report.

The provider’s policies and procedures reflect the latest best practice guidelines and latest legislation. However, the provider did not ensure they embedded the policies in managing the service. Audits to monitor the quality of care people received had been completed but they had not always been effective in improving the quality of care people received. People’s views on the care they received were gathered and reviewed to ensure any concerns were identified.

Most risks to people were identified and care planned to keep people safe. However, the people’s ability maintain healthy skin was not assessed and therefore proactive care was not in place. Risks around the environment were identified and any changed needed discussed with people. Infection control processes kept people safe from the risk of cross infection.

People were supported to have maximum choice and control of their lives and staff support them in the least restrictive way possible; the policies and systems in the service support this practice.

There were enough staff available to meet people’s care needs in a timely manner and people benefitted from having visits from a consistent group of staff who got to know them and their care needs. People told us that the staff were kind, caring and responsive to their needs. Staff received the training needed to enable them to provide safe care. They also benefitted from regular supervision meeting with the registered manager to discuss any concerns or training needs.

People had been involved in planning their care and care plans contained the relevant information needed so that staff could tailor the care to people’s individual needs. Staff worked collaboratively with other agencies to ensure any healthcare concerns were address. People’s needs at the end of their lives were identified and compassionate care was put in place.