The Lilacs 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 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 and people felt there was a positive culture at the service. Communication between people, staff and management appeared open and effective. The provider worked with members of the local community and health and social care partners to support people to live their lives fully. Staff were positive about the service and their employment, with one telling us, “We are a good team and we all support each other. Yeah, the morale amongst the staff is good.”

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 provider had a good oversight of the service. The management were supported by a compliance and governance team who visited the service regularly and had remote access of records and audits to improve monitoring. There were clear roles, responsibilities and expectations within the service. Managers encouraged staff development through training and qualifications.

Staff were positive about the management and did not raise any concerns with us, with 1 saying, “If we are struggling with anything, [deputy manager] will always be there to make sure we are ok and she always give us a hand. She does not behave like a deputy, she is part of us, and she helps me with medication and she will always help.” Healthcare professionals were positive, with 1 saying, “The Lilacs have an excellent leadership team in place with good communication.”

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

Staff said it was easy to speak up and raise any concerns with the management team. They felt listened to and supported in their roles. One staff member said, “[Deputy manager] is quite good, and she is someone who you are not afraid to go to and she listens. I have been with some managers who you dread going to, but she is really nice.” Staff meetings were held to ensure key messages were communicated and staff were enabled to provide feedback where they wished.

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.

Staff all received the same opportunities to train and develop themselves. The management told us staff were encouraged to contribute to service development through training, regular staff meetings and supervisions.

The service employed a diverse workforce, and staff did not raise any concerns about their experiences. Staff received training on communicating effectively and diversity and equality. This supported staff to understand and uphold inclusive practices in both care delivery and team interactions.

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. However, whist we identified the current governance arrangements were mostly effective, some areas of improvement were identified.

Systems included regular audits, oversight of incidents and structured review processes. Records were able to be reviewed remotely by the provider’s compliance and governance team for increased oversight. Whilst we did not identify any impact to people, we identified oversight of recruitment processes, some areas of medicines storage and emergency evacuation planning required improvement to be fully effective and mitigate the associated risks.

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.

The service maintained links with local groups and organisations so people could take part in activities and opportunities that reflected their interests, beliefs and preferences. This included visits from members of the local church. A local school had engaged with the service, and pupils had attended and sung with people. These partnerships helped people remain connected to their community and supported coordinated, person-centred care.

Care records showed the service worked well with healthcare partners, however despite our requests we received very little feedback. One healthcare professional said, “The staff are extremely caring and friendly to their residents and their families. They are always very responsive, take advice very well and action requests very promptly. Everyone knows their own role in the functioning of the home, and they come across as a great team.”

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 and management were committed to making their service as safe as possible. Systems were in place to review incidents, monitor performance and identify areas for development. Learning from incidents and audits was used to drive improvements in practice. The service regularly sought feedback from people, relatives and the staff team. A continual service improvement plan gave an oversight of actions and improvements that had been identified and when they were completed.

The provider had invested in the improvement of the environment and new flooring had been purchased and was being fitted. We observed some areas of the service were nicely decorated and well maintained. Other areas such as some walls, skirting boards and door frames required further maintenance which was part of a continual refurbishment plan.