Lyndon Croft

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 requires improvement. At this assessment the rating has changed to good
This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

The provider was previously in breach of the legal regulations in relation to good governance. Improvements were found at this assessment, and the provider was no longer in breach of these regulations
 

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 described a positive and improving culture and told us leaders listened to their views, valued their contributions and involved them in developing the service. Staff reported communication had improved and said the management team provided clearer direction and a stronger focus on achieving positive outcomes for people.

Leaders promoted an inclusive and transparent culture. The registered manager demonstrated greater oversight of the service through strengthened governance arrangements, including enhanced audits, trend analysis and regular management walkarounds. Regular staff meetings, operational meetings and daily discussions supported accountability, effective communication and continuous improvement across the service.

The provider had strengthened care planning, risk assessment and staff training processes since the previous inspection. Risk assessments and care plans more clearly reflected people's individual needs, preferences and desired outcomes. While records demonstrated improvement, we identified that further work was required to ensure staff recorded information consistently across all documentation. Leaders responded positively to this feedback and had already begun implementing additional oversight, quality assurance checks, support and targeted training to further strengthen recording practices.
 

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 management team worked collaboratively to improve outcomes for people and those important to them. Leaders strengthened systems, processes and oversight arrangements since the previous inspection to support the delivery of compassionate, person-centred care. The registered manager spoke positively about the support they received from the regional manager, which had helped drive improvements across the service.

Leaders maintained a visible presence within the home and promoted an open and approachable culture. The registered manager operated an open-door policy, while the regional manager visited regularly and remained accessible to staff. Staff told us they had seen improvements since the previous inspection and described the registered manager as committed to delivering high-quality care and improving people's experiences.

The provider invested in developing leadership capacity within the service by promoting a deputy manager from within the staff team. The deputy manager maintained a visible presence, demonstrated a good understanding of people's needs and provided support to staff and visiting professionals. The registered manager and regional manager actively supported the deputy manager's development and progression in the role.

Leaders strengthened governance arrangements and improved oversight of the service. People, relatives and staff recognised the positive changes that had taken place and the provider's commitment to improvement. While quality assurance processes had become more effective and identified a wider range of issues, further work was needed to ensure they consistently identified all areas requiring improvement and continued to drive sustained progress.

Feedback about the management team was mixed. Some people and relatives expressed confidence in the leadership of the service and the improvements made, while others identified communication as an area where further progress was needed. Overall, the provider had strengthened leadership, governance and oversight arrangements and continued to support the management team to embed improvements and further develop the service.
 

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

Staff demonstrated a good understanding of how to raise concerns and contribute to service improvements. Through regular staff meetings and supervision sessions, staff discussed practice issues, shared feedback and raised concerns. Staff told us these forums provided valuable opportunities to reflect on practice and contribute to the ongoing development of the service.
staff described an open and supportive culture. During the assessment, we observed positive and constructive interactions between managers and staff, which supported a culture of openness and engagement.

Managers actively sought feedback from staff and shared the outcomes to promote transparency and demonstrate how feedback informed service improvements. Staff understood the provider's whistleblowing procedures, knew how to access the whistleblowing hotline and described feeling confident to escalate concerns when required. The provider reinforced this through the prominent display of whistleblowing information throughout the service and by regularly discussing safeguarding and speaking-up responsibilities during supervision sessions and staff meetings.

Managers also encouraged people and those important to them to share their views. The manager told us “"When things go wrong, we are committed to being open and honest, learning from incidents and making improvements to reduce the risk of recurrence."
 

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.

The provider invested in staff development and created opportunities for staff to build their knowledge, skills and confidence. Staff accessed a range of training, development and qualification opportunities, including additional support for those who required assistance to develop their language skills or professional competencies.

Leaders promoted an inclusive workforce and supported staff from diverse backgrounds to develop and progress within the organisation.

The provider recognised and valued staff contributions through initiatives such as an Employee of the Month scheme and promoted staff wellbeing through access to an employee assistance programme, which provided confidential counselling and support services.

The provider maintained effective processes to address discrimination, bullying and harassment and promoted a respectful working environment. Leaders considered and implemented reasonable adjustments where required, enabling staff to perform their roles effectively and contribute fully to the service.
 

The provider had improved governance arrangements; however, audit and monitoring systems did not consistently identify and address risks, performance issues and documentation shortfalls.

Since the previous inspection, leaders had strengthened governance and quality assurance processes and demonstrated a good understanding of areas requiring further development. The management team introduced additional oversight measures, including a monthly risk matrix reviewed by senior leaders, to improve the identification and management of risk across the service.

Managers used audits and monitoring processes to drive improvement and had strengthened several areas, including recruitment, induction, care planning and risk management. Leaders had enhanced induction arrangements to provide clearer oversight of staff learning, competency and development.

The provider strengthened care planning oversight by recruiting 2 senior staff members and arranging additional training to develop their knowledge and skills. Leaders told us these staff would work closely with people to develop a greater understanding of their individual needs, preferences and risks, supporting the ongoing review and development of person-centred care plans and risk assessments. The provider had also strengthened the key worker system, helping staff build stronger relationships with people, improve communication with relatives and maintain better oversight of people's wellbeing and outcomes.

Although governance systems had improved, they did not consistently identify all areas requiring development. During the assessment, we identified shortfalls relating to medicines management, including PRN protocols, covert medicines documentation and an anticoagulant risk assessment, alongside inconsistencies within care planning and risk assessment records. The provider's audit processes had not identified these issues. Leaders responded positively to feedback and took prompt action to review and update documentation. They subsequently shared revised care planning, risk assessment and medicines management records to strengthen staff guidance, improve record keeping and promote more consistent practice.

Staff generally understood their roles and responsibilities and spoke positively about the support provided by the registered manager and wider management team. However, staff did not always apply this knowledge consistently in practice, particularly when maintaining accurate records and medicines documentation.

Health and social care professionals and most relatives provided positive feedback about the service and the support people received. Overall, leaders had strengthened governance, oversight and quality assurance arrangements since the previous inspection; however, further work was required to ensure audit and monitoring systems consistently identified issues at the earliest opportunity and supported sustained improvement.
 

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 provider worked proactively with external health and social care professionals, including community mental health teams and GPs, to promote positive health, wellbeing and care outcomes for people. People were supported to remain active members of their local community and access activities, groups and opportunities that reflected their interests, preferences and personal goals.

Leaders developed and maintained strong links with local faith groups, community organisations and neighbouring services, creating a wide range of opportunities for people to build relationships and participate in meaningful activities. People enjoyed visits from a local vicar, shared social events with another care service, and took part in community-based activities such as book clubs, tea afternoons and themed events. The provider also welcomed members of the local community into the home, helping people maintain important social connections and a sense of belonging.

People benefited from meaningful engagement with volunteers and members of the wider community, including support with creative projects and companionship. Intergenerational activities with children from a local nursery provided people with opportunities for social stimulation, shared experiences and enjoyment. Leaders continued to strengthen community partnerships and actively sought new opportunities to increase inclusion and participation. These initiatives helped people remain connected to the people, places and interests that were important to them, promoted wellbeing and reduced the risk of social isolation.
 

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.

At the last inspection we found the provider had failed to ensure learning from incidents, identifying trends and addressing risks to prevent reoccurrence. At this inspection we found improvements had been made. The provider had strengthened its approach to learning from incidents, concerns and identified shortfalls. Leaders demonstrated a proactive commitment to improvement by reviewing events, identifying learning and implementing changes to improve outcomes for people.

The registered manager and provider maintained effective oversight of the service by reviewing incidents, concerns and areas of poor practice, identifying trends, addressing risks and taking action to prevent recurrence. The registered manager and regional manager demonstrated a clear understanding of the service's strengths and areas requiring further development and responded promptly to emerging issues.

They also strengthened arrangements for sharing learning with staff through supervision, team meetings and day-to-day oversight, promoting consistency and continuous improvement.
The provider had addressed concerns identified at the previous inspection relating to responsiveness and communication. People, relatives and staff described the management team as more visible, accessible and responsive. Feedback was generally positive, although some relatives felt there were further opportunities to strengthen communication and ensure concerns were consistently followed through.

Leaders demonstrated a reflective and proactive approach to improvement and continued to work towards embedding sustainable changes across all areas of the service to enhance people's experiences and outcomes.