Lilibet House

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.

This is the first assessment for this service. This key question has been rated 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 71 (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 evidenced regular meetings with staff to provide updates on improvement and recruitment. This demonstrated an open and transparent culture within the home.

The operations manager, registered manager and staff team all had responsibility for ensuring actions agreed at meetings were completed. The service had a clear policy in place, with the operations manager visiting regularly to carry out their own walk rounds.

The registered manager showed a drive to improve the service and a passion to ensure the culture within the service was positive. Staff felt supported and able to share their views on the shaping of the service.

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 showed knowledge and integrity and led the service by example. The skills they brought from roles, showed in the ethos of the service. They explained how their approach to supporting people living with complex needs had become embedded at Lilibet House. They had fostered a positive culture, which was inclusive for all people, relatives and staff.

Staff felt supported by their management team. Staff we spoke with said “We feel supported by managers, they are always approachable and available to offer any support or advice, and they listen too.”

Relatives felt the registered manager and the staff team were capable, kind and showed compassion. One relative told us, “We can talk to the staff or the manager – I have their numbers here.”

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

Staff felt able to raise concerns and give feedback and feel they had been listened to. The service had a freedom to speak up policy and procedure in place. Staff told us they felt confident in speaking up if needed.

The complaints process was clear and was displayed outside the office. The registered manager operated an open-door policy. People and their relatives told us they found the management team to be available and visible.

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.

One staff member described how the registered manager was flexible in accommodating requests for things like childcare issues or personal appointments. They said, “I cannot fault the support I have received when I needed it most.”

The provider had clear responsibilities, roles, systems of accountability for good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. However, they did not always act on the best information about risk, performance and outcomes.

The provider had relevant policies and procedures in place to guide staff in relation to best practice and the governance of the service. These included business continuity plans and emergency procedures. The registered manager, deputy manager and house manager completed a range of audits to review compliance of all aspects of the service, including IPC, medicines, safeguarding, care planning and staff training.

However, we were not assured the IPC and the general safety audits were completely effective, as the concerns we found during our assessment had not previously been identified. The registered manager completed all actions immediately post assessment and evidence was provided. (See safe section of the report).

The service had established means of sharing information with staff, which included team meetings, and handovers. The registered manager was aware of which information was to be shared with other stakeholders such as the local authority. All staff were clear about their roles and responsibilities. Staff felt respected, supported, and valued by the registered manager. Staff told us they were comfortable to approach the registered manager and felt listened to.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

External professionals we spoke with confirmed staff and the management team were knowledgeable and responsive to people needs and wishes. Relationships with external professionals such as social workers and day centres were effective and supported continuity of care. The service was viewed as reliable, professional and transparent .

A relative told us "The social worker was the main support prior to using Lillibets, alongside my husband. We both agreed that it was perfect for (person). We met a couple of times with the registered manager. We were offered for (person) to attend for tea before (person) started fully; however, we felt this would just confuse (person) and decided to just start as soon as (person) was able."

The provider focused on continuous learning, innovation and improvement across the organisation. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe and effective practice.

The registered manager fully understood their responsibility to be open with people and their relatives. The provider was transparent and engaged positively during the inspection, welcomed feedback, and were committed to continuously learn and improve care. The provider told us they were moving to electronic records to develop care planning and oversight of the service.

Relatives gave positive feedback. One relative told us, “I feel the staff are fully trained to support the individuals that attend Lillibets. We were fully involved in any and all risk assessments.”