Lynden Hill Clinic

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 good. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.The service was in breach of legal regulations in relation to oversight and management of the service and governance, and failure to report notifiable events to CQC.

This service scored 46 (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 did not have a clear shared vision, strategy and culture to ensure it was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.The provider did not ensure staff had regular meetings or that minutes were taken of staff communication to evidence engagement and strategic discussions. Staff told us meetings had not taken place regularly, and there was no formal process for supervisions to be carried out regularly. This meant the provider missed opportunities to set expectations of staff and develop a shared culture when staff began working at the service. During this assessment, we identified shortfalls in the safety of the service and the support people received. The provider had failed to ensure systems had been implemented to monitor the experience of people living at the service. This had led to a culture of task-based care rather than focusing on people’s personalised care needs and experiences.Although people were complimentary about the culture and the staff team at the service from their experience, they told us they were not sure who the registered manager was or if they had ever met them. People said, “I don’t know about top management, but the administration people are visible. I’ve got a line directly to them. I’ve no idea who the management is, to be honest. I just know it is a private company” and “The management is not visible to us. We spend so much time in the room. The deputy head came around yesterday and introduced herself.”

The provider did not always ensure their leaders understood the context in which they delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.The staff team were motivated to provide care and support to people as their needs and health were changing. However, the registered manager and the provider did not ensure they promoted a positive, caring, transparent and inclusive culture within the service, especially when people experienced incidents or accidents.We received a mixture of feedback from staff. Some staff felt supported by the leaders. However, others noted not all staff had a voice to share their ideas and there was a divide in the staff team. Some staff felt the management needed improvements regarding their insight and awareness of what was going on in the service and the quality of it. They said, “When people have an issue, they could be looked after better” and “We do raise things, but I am not sure if things are taken on board.”

The registered manager and provider did not always foster a positive culture where people, their relatives and staff felt they can speak up and that their voice will be heard. We asked about freedom to speak up and the registered manager told us, “Staff are happy to tell [me] any issues and they know [I] would correct in the best way for all.”However, from evidence and feedback collected, the leaders did not always act with openness, honesty and transparency. Some staff told us they would like to be listened to more, and they did not think the registered manager promoted empowerment. They were uncertain about raising concerns as this was “not really fully valued”. There was no further evidence provided how the registered manager supported staff to raise any issues and to promote staff empowerment to drive improvement.Some staff also told us about the positive relationship they had with their colleagues. But others noted the communication between different staff teams could be improved and better organised.This would ensure when concerns were raised, the leaders investigated them properly and lessons were shared and acted on positively.People felt they could share their experiences and that this feedback would be heard. Some people felt they would receive an apology and information on actions being taken when something went wrong. However, people were not sure about the structure of the management team because who the registered manager was as they were not visible to the people. They told us, “I think I would [receive an apology]. I would feel reassured that actions would be taken to prevent that from happening again. Since I’ve met [the registered manager] the first time, I haven’t seen her. I thought [the registered manager] would ask me questions like you are, but she didn’t”, “They would apologise and would deal with it…I don’t know about the management. I don’t see the management very much” and “I absolutely feel confident in giving feedback. I think it would be acted upon. I haven’t met the manager yet. Not that I know of. Nobody has introduced themselves as the manager.” People felt staff were mostly happy and positive working at the service and worked well with people using the service.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.The registered manager did not review their policies and procedures to ensure these supported and reflected staff needs and their responsibilities. Staff were not always able to share ideas or able to contribute to the service and its development and improvements. For example, when staff made some suggestions to improve records, the management did not understand the rationale for it and told the staff there was no need for that change.Most staff supported each other however some of them also felt support and engagement from the registered manager had to improve. The registered manager did not work alongside staff delivering care or support to help them understand better any issues or disparities staff encountered. We were not assured the working environment was always inclusive, staff’s roles clearly established, and that staff’s wellbeing was considered consistently. This did not ensure the service had a positive culture which did not always support better outcomes for people.The provider and the registered manager did not always demonstrate how they took action to continually review and improve the culture of the organisation in the context of equality, diversity and inclusion.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or shared this securely and timely with others when appropriate.They did not always assess, monitor and mitigate any risks relating to the health, safety and welfare of people using the service, staff and the operation of the service. The provider’s quality assurance systems did not identify concerns we found during this assessment which are described throughout this report.

The registered manager did not maintain an effective oversight of the quality of care being provided, risk management and mitigation, staff practices, knowledge and competency to support people. The registered manager did not monitor recruitment checks were appropriately carried out to ensure all required information was gathered to ensure there were suitable staff to work with people.The people were not consistently safeguarded from the risk of harm. Staff were not always adequately trained and competent prior to providing care and treatment.The provider or the registered manager could not demonstrate how they proactively looked at trends or themes in the incidents, accidents and complaints that occurred so that were able to identify areas of concern and take action to prevent reoccurrence and safeguard people.The provider or the registered manager did not demonstrate how they used audits continuously to identify and monitor the risks to people for different aspects of their care such as medicine, moving and handling, and wellbeing. The provider and the registered manager did not ensure management of medicine was safe and proper including checks for medicine competencies.The provider did not gather feedback from people and/or relatives about the quality of care provided to show how they used the feedback to develop the service and drive improvements.

The registered manager told us questions would be asked during staff supervision. However, the provider did not establish surveys for staff or any other stakeholders so they could gather information and suggestions that could support service management and development.The provider did not always ensure accurate, complete and legible records were maintained or updated when necessary to support effective management of people’s care and treatment, staffing and the service. The provider did not demonstrate they were aware of people’s individual needs to ensure safety from the risk of harm. There was no real oversight to identify if risk assessments and care plans were in place, followed and reflected in people’s daily notes.This meant they were not able to demonstrate how they identified and worked on the areas where improvements were needed.

During this assessment, we found the registered manager had failed to notify CQC of a number of reportable events including allegations of abuse, thefts and serious injuries. We spoke with the registered manager who told us they were unsure of the need to report notifiable events to CQC. There was a lack of knowledge and understanding relating to notifications and the need to submit them to CQC.

The provider and the registered manager did not always understand their duty to collaborate and work in partnership with all relevant external stakeholders and agencies, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement or review risk mitigation. The registered manager told us how they worked with a service nearby if they had any issues with admissions and people were unsuitable for the service. They also told us they kept in touch with another service providing rehabilitation services. The service was visited by a GP on a regular basis to review people’s health. However, the registered manager was not able to provide any further examples demonstrating how they collaborated and worked in partnership with other services to ensure continuity in people’s care and to achieve the best outcome for people using the service. Some staff felt there needed to be more external oversight to support the service management and governance. They noted they would gather different information, but they were not sure how it was used to support oversight of the service. This did not ensure staff and leaders were able to engage with people, communities and partners to share learning with each other that resulted in continuous improvements to the service. Opportunities were missed to use these networks to identify new or innovative ideas that could lead to better outcomes for people and maintain a learning culture in the service.

The provider and the registered manager did not always focus on continuous learning, innovation and improvement across the organisation and local system. The provider did not have a clear process and did not use their polices to focus on continuous learning and improvement from incidents, reportable events, audits and information gathered at the service. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. The registered manager could not provide examples how they actively contributed to safe, effective practice and research that could also encourage reflection and collective problem-solving. Staff and leaders did not ensure people using the service, their families and carers were involved in developing and evaluating improvement and innovation initiatives. Staff confirmed they did not have regular staff team meetings to discuss items, issues or feedback arising from running of the service. Staff felt this was missing in the service as this would give them the opportunity to discuss important aspects of the service and identify areas needing attention. The registered manager did not use their policies and procedures to support the process of learning, measuring outcomes and impact or the services provided. Where we identified shortfalls during this assessment, the registered manager was responsive to our findings and started working on areas of improvement.From staff’s feedback and our findings of issues, we were not assured the provider and the registered manager consistently encouraged staff to speak up with ideas for improvement and innovation and actively listened and engaged with them.