# Lily Health Care Limited

*Operated by Lily Healthcare Limited.*

Lily Health Care Limited is a CQC-regulated home-care agency in Dudley.

## CQC Ratings

| Key question | Rating |
| --- | --- |
| Overall | Requires improvement |
| Safe | Requires improvement |
| Effective | Good |
| Caring | Good |
| Responsive | Good |
| Well-led | Requires improvement |

Rating published: 08/12/2023

## Practical info

- Postcode: DY5 1HA
- Registered manager: Chitura, Mary
- Local authority: Dudley
- Region: West Midlands
- City: Dudley
- Last CQC check: 08/Dec/2023 - 00:00

## Inspection findings

### Other

- Finding
  - Evidence: Sufficient staff were available to support people and staff felt supported and valued by management.
  - Published: 2023-12-08
- Finding
  - Evidence: Safe infection prevention and control practices were in place, with staff using appropriate PPE.
  - Published: 2023-12-08
- Finding
  - Evidence: People and relatives spoke highly of care staff, describing them as 'absolutely brilliant' and 'amazing'.
  - Published: 2023-12-08
- Finding
  - Evidence: Registered manager was open, transparent and receptive to feedback, taking immediate action to address shortfalls identified during inspection.
  - Published: 2023-12-08
- Finding
  - Evidence: Staff protected and respected people's privacy and dignity, promoting equality, diversity and culturally appropriate care.
  - Published: 2023-12-08
- Finding
  - Evidence: People were supported to have maximum choice and control; staff worked within the principles of the MCA and sought consent before every interaction.
  - Published: 2023-12-08
- Finding
  - Evidence: Staff understood how to protect people from poor care and abuse, with training on recognising and reporting abuse applied effectively.
  - Published: 2023-12-08
- **staffing_levels** _(moderate)_
  - Evidence: Where staff had commenced employment and shadowing experienced staff before the return of their DBS check, a risk assessment had not been undertaken.
  - Published: 2023-12-08
- **record_keeping** _(moderate)_
  - Evidence: Late and missed calls were not recorded, and there were no systems to monitor when staff arrived and left their care calls.
  - Published: 2023-12-08
- **staff_training** _(moderate)_
  - Evidence: Some staff had not received training in relation to some of the medical conditions of the people they supported. For example, spinal injury, and stroke.
  - Published: 2023-12-08
- **medication_management** _(moderate)_
  - Evidence: We found gaps in 1 person's records, which had not been explored, and handwritten medication records had not always been signed by the staff member.
  - Published: 2023-12-08
- **incident_learning** _(moderate)_
  - Evidence: Accident and incidents had not always been recorded since our last inspection to demonstrate what action had been taken to reduce risks for people.
  - Published: 2023-12-08
- **governance** _(critical)_
  - Evidence: The provider did not have effective systems and processes to ensure effective oversight of the service was maintained. Breach of regulation 17.
  - Published: 2023-12-08
- **care_planning** _(critical)_
  - Evidence: Risk assessments did not always contain detailed information about people's risks... actions staff should take to minimise these risks were not always detailed.
  - Published: 2023-12-08

### safe

- Finding
  - Preventing and controlling infection
  - Published: 2023-12-08
- Finding
  - Systems and processes to safeguard people from the risk of abuse
  - Published: 2023-12-08
- Finding
  - Learning lessons when things go wrong
  - Published: 2023-12-08
- Finding
  - Using medicines safely
  - Published: 2023-12-08
- Finding
  - Staffing and recruitment
  - Published: 2023-12-08
- Finding
  - Assessing risk, safety monitoring and management
  - Published: 2023-12-08

### well_led

- Finding
  - Working in partnership with others
  - Published: 2023-12-08
- Finding
  - Continuous learning and improving care
  - Published: 2023-12-08
- Finding
  - How the provider understands and acts on the duty of candour
  - Published: 2023-12-08
- Finding
  - Promoting a positive culture that is person-centred, open, inclusive and empowering
  - Published: 2023-12-08
- Finding
  - Engaging and involving people using the service, the public and staff
  - Published: 2023-12-08
- Finding
  - Managers and staff being clear about their roles and understanding quality performance, risks and regulatory requirements
  - Published: 2023-12-08

## Source

Data published by the [Care Quality Commission](https://www.cqc.org.uk/) under the Open Government Licence v3.0. Canonical page: https://homecarecompass.co.uk/agency/1-2025119557

HomeCare Compass is an independent guide and is not affiliated with the CQC.