The Lawn Residential Care 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 inspection we rated this key question good. At this inspection the rating has changed to requires improvement.

This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

We found a breach of regulation in relation to good governance.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service 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.

People and relatives were complimentary about the culture in the service.

Staff knew people well and spoke knowledgeably about the people they supported.

Staff told us they liked working at the service and felt part of a team. A staff member said, “I love this job.”

The registered manager engaged with people and staff and had an open-door policy.

The service 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.

People and relatives were complimentary about the registered manager. As the registered manager was new to the post, not all relatives had met them. Relatives felt they could approach the registered manager and other staff if they needed help. A relative said, “There have been opportunities to meet the new registered manager.[My family member] has had conversations with him several times.I think it is appreciated that he makes the effort to chat with the residents.”

Staff spoke positively about the registered manager and told us they felt able to ask for support if needed.One staff member told us, “The registered manager is approachable and very easy to speak to.” Another staff member said, “The registered manager is approachable. They are a nice person.”

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

Staff confirmed they knew how to whistle blow and to report concerns to external organisations if necessary. There was a culture of speaking up where staff were able to raise concerns without fear of detriment.

The provider had up-to-date policy in relation to safeguarding.

The registered manager was aware of their responsibilities and the importance of supporting staff to speak up.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

Surveys were available to staff. Records showed the provider was responsive and shared the results of surveys with the staff. This meant staff were empowered to contribute to service improvements, knowing their feedback was acknowledged and acted upon.

The service was an inclusive workplace where staff were treated and supported as individuals. New staff completed a health questionnaire form in case any reasonable adjustments at work should be explored. Records confirmed reasonable adjustments were implemented where required.

The service did not always have clear systems of accountability or good governance.

Governance systems in place were not always robust, and audits were not always effective. Some environmental risks such as the risk of choking on readily available food items, were not identified and assessed. The medicine management and people’s care plans were audited regularly, however, these did not identify or address the shortfalls found during this inspection. This increased the risk of repeated issues, missed opportunities for learning, and placed people at an increased risk of avoidable harm.

Two notifications of outcome of an application to deprive a person of their liberty (DoLS) were not submitted to CQC as required. A notification is the action that a provider is legally bound to take to tell us about any changes to their regulated services or incidents that have taken place in them. Both notifications were submitted retrospectively.

In response to our inspection feedback the registered manager introduced a plan for improvement to address the shortfalls identified. The improvements made needed to be embedded into practice and sustained.

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

The provider had a good working relationship with health and social care partners. Records confirmed the service communicated with a wide range of health and social care professionals. They understood their duty to collaborate, share information and work in partnership. A professional said, “The staff are friendly. The rapport I see is good.”

The service 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 provider had systems for sharing lessons learnt with staff.

The registered manager was committed to making sustainable improvements within the service. These included separate department meetings, PPE stations for staff and fostering new relationships with the local communities. The registered managerunderstood the importance of continual improvement within the service.