Liversage Court 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 Good. At this assessment the rating has changed to Requires Improvement. This meant that the governance processes did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance at the service.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders had set out expectations for staff behaviour and standards of care; however, these were not always consistently embedded in practice.

Managers were clear about the standards they expected. Team meeting minutes showed they identified areas for improvement and outlined how they expected staff to act, including challenging poor practice. Staff we spoke with understood these expectations and told us they would raise concerns with management where needed. However, inspection findings demonstrated that standards of care, including meeting people’s basic needs and treating people with kindness, were not always met in practice.

Some people and relatives provided positive feedback about the home. One person told us, “It’s got a nice atmosphere and you get to make friends,” and another said, “It’s generally just a good place to live.” A family member commented, “I think it’s happy and welcoming.” A professional noted, ‘Staff are kind and responsive to residents and the atmosphere is welcoming and transparent.’ However, this feedback was not consistent with all of the experiences observed during the inspection.

Leaders were compassionate and inclusive. Leaders monitored the service and took action to improve the service though they had not identified and addressed the issues we found during this assessment.

People praised management. A person said, “It’s first class with the manager.” A relative said, “We feel welcome here and can talk to any of the management team.”

Leadership was described as supportive. A staff member said, “The manager is fantastic and will sort any problems.” Another staff member said, “The manager is really good.” Team meetings showed clear communication between management and staff. Staff told us that they were happy to raise any concerns during meetings.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

People felt able to speak up and raise concerns. Staff were confident raising issues with management and felt they would be acted upon. A staff member said, “I would definitely report concerns to management and am confident that they would take action.” A whistleblowing policy was in place.

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. Policies were in place to support workforce equality. Staff raised no concerns in this area and felt that they were treated fairly at work.

Governance and management systems were not fully effective. Governance processes were in place and some audits were completed, however these processes had not identified and resolved the issues we found at this assessment. These included weaknesses in infection, prevention and control oversight, where IPC audits did not identify concerns and care plan audits that had not identified missing care plans, poor fluid recording or care plans that required further development. Oversight of the management of the home was limited. The provider planned to change staff structures to strengthen auditing processes.

Care Quality Commission (CQC) notifications were not always being submitted as required and the provider had not ensured that they had identified all the service user bands that they were providing support for.

A range of policies were in place regarding information governance and the use of information. The provider had achieved an ‘exceeded’ rating for the Data Security and Protection Toolkit standards and achieved standards for cyber essentials plus, a data security accreditation.

The CQC rating was displayed and registered managers were in place.

The service worked in partnership with others for people’s benefit. Processes were in place to ensure suitable referrals to other community partners and agencies and had been appropriately followed by staff.

A professional commented, ‘When we give advice regarding a [person’s] treatment or care needs, they usually try to implement this and at present there are no concerns regarding the care provision.’

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system.

Staff completed a range of audits and areas for improvement were discussed with staff. However, these processes had not identified and resolved the issues we found at this assessment.