The Lilacs Residential Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.
 

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 provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. The registered manager shared their vision for people to be able to live in a happy homely environment whilst maintaining choice and independence. Staff shared this vision, one member of staff said, “I enjoy being with residents and making their days better.” Another member of staff said, “I enjoy working here and listening to people’s stories.”

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. The registered manager kept their skills up to date and develop their knowledge with further training and professional development. Staff were also supported to develop their skills and knowledge.
Staff informed us they felt supported by the registered manager. One member of staff said, “The manager is very approachable you can go to them with any problems.” Another member of staff said, “The manager is always available even when they are not working or on holiday, they will answer their phone and answer any questions.”
 

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The registered manager acted with openness, honesty and transparency. Staff were encouraged to speak up during staff meetings and 1:1 supervision. One member of staff said, “I find supervisions a good opportunity to discuss anything I want with the manager.” There were policies in place to support staff with ‘whistleblowing’ and freedom to speak up. Staff told us they felt confident to speak up and believed they would be listened to and action taken.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Staff were treated fairly at the service and there were policies in place to support this. Staff received training on equality and inclusion, and this training was embedded through discussions in staff meetings.
Staff told us they felt they had a good team and enjoyed working at the service.
 

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. The registered manager had good oversight of the service through the quality assurance systems they had in place. There was a focus on continual improvement at the service to provide positive outcomes for people.
There were regular quality assurance surveys for people, relatives, staff and stakeholders to provide feedback on the service delivery. These surveys were analysed and actions put in place where needs were identified.
The provider arranged for external audits to be regularly undertaken from registered managers within other services they owned. This gave an opportunity for shared learning whilst bench marking standards the provider expected from all their services.
The registered manager understood their responsibility under duty of candour to be open and honest when things went wrong and investigate these. Notifications were raised promptly to the appropriate authorities when required these included the CQC and local authority safeguarding team.
 

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. The registered manager worked with other healthcare professionals to ensure people’s healthcare needs were being met and reviewed. This included GPs, district nurses, palliative care, occupational therapist, dentists and footcare providers. Where people needed hospital reviews and specialist appointments, people were supported to attend these.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. The registered manager shared learning at the service from accident, incidents, complaints and safeguarding concerns to mitigate risks and improve outcomes for people. Staff were encouraged to share their feedback during meetings and supervision to help with the development of the service. Staff had been encouraged to develop their skills with additional training to equip them with the skills they needed.
The registered manager networked with other registered managers learning and ideas to improve practice within services.