Lancaster Court

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

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.

Most staff described positive working relationships between colleagues and support from managers. People and relatives gave positive feedback about how the service was managed.

The provider had policies to support equal opportunities and inclusion. A staff member told us, “The home manager is emphatic, supportive, transparent and open towards all members of staff.”

Most staff spoke positively about the registered manager; they found them supportive and approachable. However, we did receive some negative feedback around their understanding of people’s needs and the impact on the staff. We were also told too much was delegated to nurses. During our visits we found the registered manager tended to refer to staff when asked about people’s needs. We discussed this with the provider, and they did not feel any tasks assigned to nurses were outside their role and the registered manager told us they did staff supervisions instead of the nurses now.

Staff knew who to approach if they needed to raise concerns and the majority felt comfortable about doing this. In addition to their manager, they mentioned other people within the organisation they could approach as well as the local council or CQC. However, 1 staff member said, “Many staff members are scared to speak up due to fear of repercussions.”

Staff gave mostly positive feedback about support from managers and colleagues.

The provider had policies to support fair treatment of staff.

The registered manager’s processes for monitoring the quality of the service were not always effective. Whilst audits were completed, they had not identified the gaps we found in people’s records. Where issues were identified, such as injuries to people when staff supported them to transfer, action taken was not robust to reduce the likelihood it happened again. We reviewed their service improvement plan which included an action for medicines protocols to be done but we found issues with these during our visit.

The home worked well with other services. A professional said, “The senior members of the team manage the home well from my perspective.”

The registered manager’s processes to support learning and improvement were not always effective. We reviewed meeting minutes which showed some of the concerns we had were raised: moving and handling injuries, staff presence in communal areas and documentation of activities. However, given these remained an issue during our visit we were not assured action taken was enough to improve.

The provider was responsive to the concerns we raised during the inspection. They took action to update records where we found gaps.