Lillington 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.

At our last assessment we rated this key question good. At this assessment the rating has remained 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.

Staff were very motivated and enthusiastic to provide people with the highest standards of clinical and personal care. Staff demonstrated understanding and empathy about people’s personal situations and worked together to achieve the best possible outcomes for them. One staff member told us, “Every member of our team is passionate about the work we do and the difference this makes to people’s lives.” Another staff member commented, “Society often measures success as have things got better, is the person mended? That’s not possible here. We focus and celebrate small wins and what’s important to the person.”

Staff described good teamwork and effective communication and were encouraged to share ideas and strategies to improve the service and deliver high quality care. Professional challenge and collaborative working promoted a learning culture to benefit people and maximise opportunities for improvement. One staff member told us, “To come in and think you are making a difference to someone else’s day is just amazing."

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.

There was a clear management structure in place. The registered manager was supported by a clinical manager who maintained day to day oversight of the service. Staff said the clinical manager was very visible, had a good understanding of people’s needs and recognised the day-to-day challenges of providing support to people requiring complex nursing interventions as they worked nursing shifts. One staff member told us, “[Clinical manager] is lovely. She has a walk round each day; she is on the floor working as a nurse when it is needed and she is very approachable. She makes herself known, she has lunch in the staff room with everybody. She is always there to support you through everything.” Another staff member commented, “[Clinical manager] sometimes works on the floor, she wants to learn about the residents and what is going on.”

People and their relatives knew who the registered manager was and were positive about their management of the service. Comments included: “I like [registered manager], he is good”, “The manager is very nice, he seems very efficient”, “[Registered manager] is a good manager, very accessible” and “The manager’s good, he knows what he is doing.” A visiting healthcare professional described the registered manager as, “Accessible.” They added, “Any problems, they talk to me and I talk to them, but everything runs smoothly."

Staff had regular opportunities to meet with their direct line manager and discuss their wellbeing and any support they needed. One staff member told us, “I have clinical supervision every month formally but to be honest we work so closely with [line manager] we have daily discussions and opportunities to seek advice and talk things through.”

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

Staff were encouraged to speak up and felt supported and safe to do so. One staff member told us, “I don’t ever feel I can’t go and speak to [name of managers]. The management are very friendly, and they do listen to you." Another staff member told us they would feel confident to report poor practice within the staff team. They commented, “All the staff are so friendly but if I feel something is not right, I will go and tell the nurse on the floor."

The provider had processes to support staff to speak up. This included supervision meetings, handovers, staff meetings and a whistleblowing policy. The provider’s liaison officer was available to staff and could provide guidance and help facilitate conversations to resolve any issues or concerns.

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.

People received support from a diverse staff team who felt valued and recognised for the work they did. Staff described an inclusive culture and gave examples of being supported to manage their own personal caring commitments. The provider had policies to support workforce equality, diversity and inclusion and these were available and accessible to all staff.

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.

Checks and audits were used to monitor risks and performance and to understand where improvements were required. Checks of clinical care and safe medicines management were robust and ensured people received high standards of treatment and support. However, some checks needed improvement, such as making sure infection control policies were consistently followed and ensuring timely actions were taken in response to the external fire risk assessment. These shortfalls were immediately addressed during our inspection.

The registered manager maintained oversight of checks and audits. They prepared a report which was presented to monthly meetings of the senior management committee who had responsibility for running the service under the direction of the Board of Trustees. The senior management committee monitored the standards of clinical care, quality and safety.

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.

Managers and staff had built strong relationships with external health and social care partners to share learning and improve people’s experiences. External professionals provided positive feedback about information sharing and joint working to ensure people received the right support against a background of complex clinical and medical needs.

Relatives were treated as partners in their family member’s care. They told us they were involved in decision making and were informed about any changes in their family member’s health or wellbeing. One relative said, “We get phone calls about any changes to their health or appointments, they always keep us updated.”

The provider issued a regular newsletter to inform people and staff of any changes within the organisation.

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. They actively contributed to safe, effective practice and research.

The provider reviewed people’s care and developed case studies to identify areas of good and outstanding practice and where learning had been identified. Learning was shared with other organisations to promote the benefits of interdisciplinary working and inform the practice of other healthcare professionals.

Staff were encouraged to explore and consider new ways of working to develop their own practice and ensure positive outcomes for people. For example, clinical staff had developed their own training package to support care staff to safely manage external tubing associated with catheter, nephrostomy and PEG care. One staff member told us, “We are all very open and willing to share ideas and problem solve. You can say, ‘I thought about trying this, what do you think? Or do you have any advice about X’. It’s a very positive way to work.”

The provider, registered manager and therapy staff attended national conferences to share their experiences and to explore innovation and developments in the treatment of adults with an acquired brain injury or neurological condition.