# LlyonHealth

*Operated by Llyon Health Ltd.*

LlyonHealth is a CQC-regulated home-care agency in Sale.

## CQC Ratings

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

Rating published: 20/11/2024

## Practical info

- Postcode: M33 3AQ
- Registered manager: Mavindidze, Tammy
- Local authority: Trafford
- Region: North West
- City: Sale
- Last CQC check: 20/Nov/2024 - 00:00

## Inspection findings

### effective

- Finding
  - Ensuring consent to care and treatment in line with MCA
  - Published: 2023-07-06
- Finding
  - Working with other agencies to provide consistent, effective care
  - Published: 2023-07-06
- Finding
  - Supporting people to eat and drink enough
  - Published: 2023-07-06
- Finding
  - Assessing people's needs and delivering care in line with standards
  - Published: 2023-07-06
- Finding
  - Staff induction, training, skills and experience (Regulation 18)
  - Published: 2023-07-06

### Other

- Finding
  - Evidence: Staff understood and applied principles of the Mental Capacity Act 2005.
  - Published: 2023-07-06
- Finding
  - Evidence: People's needs were assessed before starting the service and care plans were personalised.
  - Published: 2023-07-06
- Finding
  - Evidence: Staff liaised with healthcare professionals and other agencies to support people's independence and health.
  - Published: 2023-07-06
- Finding
  - Evidence: Effective infection prevention and control procedures were in place including PPE use.
  - Published: 2023-07-06
- Finding
  - Evidence: People's care plans contained up to date risk assessments and management plans.
  - Published: 2023-07-06
- Finding
  - Evidence: Medicines were generally managed safely and all staff administering medicines had received training and annual competency checks.
  - Published: 2023-07-06
- Finding
  - Evidence: An electronic call monitoring system was introduced to improve oversight of staff scheduled visits.
  - Published: 2023-07-06
- Finding
  - Evidence: Improvements had been made to call times and no missed calls were reported at this inspection.
  - Published: 2023-07-06
- **record_keeping** _(moderate)_
  - Evidence: Information such as accidents, incidents and training information were not always readily available to view on site.
  - Published: 2023-07-06
- **leadership** _(moderate)_
  - Evidence: The registered manager was not available for the 2 days we visited their office...The provider failed to submit this action plan.
  - Published: 2023-07-06
- **incident_learning** _(critical)_
  - Evidence: The registered manager lacked awareness of their statutory responsibilities in relation to safeguarding statutory notifications to inform CQC of certain safeguarding incidents.
  - Published: 2023-07-06
- **medication_management** _(moderate)_
  - Evidence: We reviewed MAR charts and found a number of gaps. The registered manager did not ensure these omissions were reviewed appropriately.
  - Published: 2023-07-06
- **supervision_appraisal** _(moderate)_
  - Evidence: We found many supervision forms had been pre-populated and not discussed with the individual staff member.
  - Published: 2023-07-06
- **governance** _(critical)_
  - Evidence: Audits completed had not always identified the concerns we found on inspection. There was an overreliance on office staff to complete a number of quality checks.
  - Published: 2023-07-06
- **safeguarding** _(critical)_
  - Evidence: A staff member not attending a call, falsifying records, and not reporting a person's catheter being removed...had not been reported the local safeguarding team or CQC.
  - Published: 2023-07-06

### safe

- Finding
  - Preventing and controlling infection
  - Published: 2023-07-06
- Finding
  - Assessing risk, safety monitoring and management
  - Published: 2023-07-06
- Finding
  - Learning lessons when things go wrong / safeguarding
  - Published: 2023-07-06
- Finding
  - Using medicines safely
  - Published: 2023-07-06
- Finding
  - Fit and proper persons employed (Regulation 19)
  - Published: 2023-07-06
- Finding
  - Staffing and call scheduling
  - Published: 2023-07-06

### well_led

- Finding
  - Working in partnership with others
  - Published: 2023-07-06
- Finding
  - Duty of candour and statutory notifications
  - Published: 2023-07-06
- Finding
  - Staff culture and workforce conditions
  - Published: 2023-07-06
- Finding
  - Governance, oversight and regulatory compliance (Regulation 17)
  - Published: 2023-07-06

## 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/1-5242445854

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