Leggyfield Court (Care Outlook)

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• 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. This is the first assessment for this service. This key question has been rated requires improvement.

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

The service was in breach of the legal regulation in relation to 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 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 reported an open, supportive culture with valued management relationships, active professional boundaries, and a strong promotion of team diversity. For example, staff chose to perform cultural dances for people showcasing their heritage and dedicated their own time to practicing these dances. A staff member said, “We celebrate our cultures around 3 times a year and put on a show for the people we support in the form of a dance, we practice in our breaks and dress in our traditional outfits. People seem to really enjoy the experience, and it’s helped to bond us all together.” Another member of the team said, “The culture is good here we all respect each other.” This commitment promoted an inclusive environment where people felt respected and trusted the staff supporting them. We observed staff providing people support in a familiar friendly way reflecting the provider’s values and this was also reflected in interactions between the registered manager and staff team.

The provider had inclusive leaders at all levels who understood the context in which they delivered care 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 staff spoke positively about their support and interactions with leaders in general. One person said, “The manager is nice and I know where to find her if I need to.” A staff member said, “Since we have had a consistent manager it’s been better.” The registered manager involved staff in decisions around how the service operated and listened to their feedback. Another staff member said, “If we tell the manager a person’s needs have changed, they listen to us and reassess their care, I feel involved in the process.”

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

Staff knew the routes they had available to make their voices heard and told us the registered manager listened to their feedback. One staff member said, “I raised concerns with the manager, and they acted and addressed them.” Another staff member said, “It’s easy to speak with the manager and I can make suggestions.” The registered manager supervised staff and held team meetings in which staff were able to voice ideas and discuss any challenges they faced. Team meeting documents showed the registered manager addressed issues staff raised.

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

Staff told us how the registered manager treated them with respect and valued the strengths their culturally diverse backgrounds brought to the team. Staff consistently described the team as feeling like a family who care about each other. One staff member said, “We have a nice team here and help each other.” Another staff member said, “I’m really happy to work here the manager is really nice.” And another said, “We all come from different places, but it feels like we are brothers and sisters here, we share our different food with each other which I really like.” Training in equality and diversity was provided to all staff. All these factors contributed towards creating an inclusive environment in which staff felt valued and empowered to fulfil their roles.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

We found shortfalls in the provider’s governance processes around assessing, monitoring and mitigating risks to people, safeguarding referrals and management of medicines. For example, we observed a staff member responding to a person experiencing a health emergency without guidance on how to respond in this situation. Other risks had not been identified and mitigated including environmental risks to people who experience emotional distress, and risks around a change in how someone managed their medicines. A staff member said, “Most people have care plans in their flats but sometimes they aren’t there before we give care if someone is new, we tell the manager and they put it in place.” Systems did not consistently assure that safeguarding concerns were recognised and acted on.

Audits had not always identified discrepancies between the care plans and the current situation. For example, a person’s care plan stated their medicine was kept in a locked cupboard, but we observed this not to be accurate. Discrepancies in recording of medicines had not always been identified. The registered manager did complete annual care plan audits and had effective oversight of staff training and competency compliance.

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 registered manager had supported people to access their local community and provided engagement for people to socialise in communal areas where they had the opportunity to share activities facilitated by staff which helped to build a community within the service. People were supported to access other health professionals when needed including occupational therapists and district nurses and built positive professional relationships promoting good outcomes for people.

The provider focused on continuous learning, innovation and improvement across the organisation and local system.

The provider had recently implemented supportive roles within the leadership structure of the service including a quality manager and a role responsible for medicine oversight, to support improvement. The registered manager held team meetings and discussed any learning from incidents, accidents and listened to staff feedback regarding people’s care and support.