Lee Valley Care Services Limited

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 remained 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.

The service was in breach of a legal regulation in relation to good governance. The provider did not have effective governance and quality assurance systems to monitor, assess and the improve the quality of the service.

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.

While the provider had a clear vision, strategy, and culture promoting transparency, equity, equality and human rights, observations and our findings during the assessment indicated that these values were not yet fully embraced by the service and consistently embedded across all care practices.

While the provider and staff members demonstrated a collaborative approach, they have not always acted in a timely way to improve the safety culture within the service and have not always demonstrated an inclusive culture, where people were actively involved in their care and in managing risks. For example, managers had not identified and mitigated risks to service users and involved them in the review of the risks and their changing needs. This meant that people were not always being appropriately protected from the risk of avoidable harm.

While the culture within the service was to ensure people lived their lives fully and within a pleasant and maintained environment, the provider had not identified, assessed or taken action to mitigate the risks associated with the spread of infection, cleaning products that had expired, and in addition the service was in need of a deep clean, which had not been identified by the provider or their staff. As a result, the provider was not always meeting their stated objectives with clear actions.

Despite the concerns we identified during the assessment, the leadership team responded positively during the assessment and demonstrated their willingness to improve, however we were not assured governance processes to ensure people consistently received good quality care and improved outcomes were effective.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation.

Leaders had not maintained sufficient oversight or established systems to ensure the safety and quality of the service which was not consistent with the expectations of capable, compassionate and inclusive leadership. They were not alert enough to identify the shortfalls we identified at this service in terms of risk management and medicines management, so they could make the necessary improvements promptly

The provider’s records did not demonstrate regular checks had been undertaken at the service and did not always capture all required actions. This did not support the development and safety of the service. In addition leaders had not fully understood and addressed the requirements and recommendations made by CQC, at their previous inspection so they could make the necessary improvements.

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

Staff knew and understood how to raise concerns and had knowledge of whistleblowing processes and the freedom to speak up.

The service had a whistleblowing policy and procedure. Staff demonstrated an understanding of whistleblowing and could explain what they would do if they needed to escalate concerns about poor practice.

A staff member told us, “We have regular supervisions, and each time I raise concerns, the management listens”. Another staff member told us, “If I have something to say I feel listened to and my concerns taken seriously.” Leaders acted on the information appropriately, which reinforced a culture of transparency and trust within the service.

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 workforce came from a range of ages and experiences and leaders recognised and valued the different skills, perspectives and experiences staff brought to their roles. Leaders supported staff with opportunities for career development and progression which encouraged staff growth, confidence and retention within the service. A staff member told us, “Managers are supporting me to do my NVQ level 3.”

Leaders had arranged equality and diversity training for staff. Staff understood the importance of inclusive practice and how this supported positive working relationships, benefiting the vulnerable people they supported. This helped promote a culture where people`s individuality, backgrounds and protected characteristics were respected and valued.

The provider had not established or operated effective systems of governance. This had led to shortfalls which could have compromised the safety of people using the service, including concerns around risk and care plans and medicines administration.

The provider’s systems and checks of medicines were not robust and had failed to highlight gaps that were picked up during the assessment and related to staff knowledge and practice around the management of medicines.

Staff were administering insulin to a person when there was no involvement of district nurses or evidence of delegating this task by an external professional. As a result the provider could not demonstrate they were following national guidance when administration of specific medicines or other healthcare tasks were delegated to the care staff.

Managers told us they reviewed care and risk plans on a regular basis however these checks had not identified the areas of concerns we found. Furthermore, premises and equipment audits had failed to identify some of the shortfalls including concerns around the storage of cleaning products and maintenance of the environment. The infection control audits and checks have also not been robust enough as we identified ineffective arrangements in regard to hand washing.

During the assessment, some immediate remedial actions were taken to address some of the environmental concerns for example handwashing detergents and paper towels were placed in the bathrooms, after we had identified these were not in place.

The provider understood their duty to collaborate and work in partnership, so services worked for people. They shared information with partners and collaborated for improvement.

The registered manager and staff told us they worked closely with various health and social care providers, and positive relationships had been built. Partners confirmed this. Specific comments included “The registered manager always spoke and communicated with me directly,” and “I always received a verbal handover and when needed, a review of documentation.”

The provider did not always focus on continuous learning, innovation and improvement across the organisation. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The manager told us they had been working on improvements to the service since the last assessment and had implemented a new electronic care recordssystem. Furthermore, they had developed action plans to address issues that were picked up then to make improvements.

The management team were able to demonstrate that some identified areas for improvements were being progressed, with some actions already completed.

However, during the assessment we identified concerns which had not been identified through the service’s own governance systems. We have also identified breaches of regulations in relation to safe care and treatment and good governance. These were the very breaches of regulations that we had identified at the last inspection in June 2023. This showed opportunities for learning and service improvement were sometimes missed and further work was needed to ensure concerns were identified promptly and addressed and that any improvements made were embedded and sustained over time.