Lindau 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 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 legal regulation in relation to governance at the service.

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.

Information about the vision, strategy and culture was available around the service for people, relatives, visitors and staff. The provider and management team were passionate about the service and wanted to ensure people had good quality care and improved outcomes. The provider had told CQC through the submission of their provider information return (this is information CQC request from providers on an annual basis) about their vision. They stated, ‘Our home has the ethos treat others as you would wish you and your family members to be treated. Irrespective of who you are, where you are from or from what culture, everyone has the same voice to be heard regardless if you live in a care home or in your own home. All our staff are respectful towards each other, residents, family members and visiting professionals.’

Staff gave positive feedback about the culture of the service. Staff reported a positive open culture where they felt empowered to raise any concerns or make suggestions. Comments included, “It is definitely a good culture everyone gets on and it’s a good team” and Staff are very nice and so is the manager, she gives reassurance to staff and residents.”

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 knew people well and were passionate about making sure people received good quality care. There was a clear management structure in place with the registered manager, a deputy manager and an operations manager. The service also employed team leaders, senior care workers and care workers to provide care and support. Staff understood their responsibilities to meet regulatory requirements. The registered manager was supported by the nominated individual for the provider who visited the service regularly to undertake checks and audits. The management team told us they were well supported by the provider. Daily handover meetings were held so staff had up to date information about the people they were supporting. Staff told us the management team were supportive and approachable.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff confirmed they were invited to meetings and encouraged to contribute. Staff meeting minutes evidenced that these took place regularly. Complaints processes were available. People knew who to talk with if they had concerns or complaints. This included reporting their concerns to staff, or the registered manager. We observed people and relatives visiting the registered manager in their office and were supported appropriately. A person told us, “The manager [name] makes us all feel safe. She reassures us. She does a good job.”

Relatives knew who the registered manager was. Comments included, “[Registered manager] is a very fierce woman and is a very good manager. I would give them 10/10” and “I can chat to [registered manager] if I have any worries. She listens to me.”

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 was diverse, and support was in place for staff. Any issues could be discussed openly at staff meetings or during supervision. The registered manager had an open-door policy and staff told us they would not hesitate to speak to the registered manager if they needed to. Staff reported the staff all worked together well as a team. Staff told us, “[Registered manager’s] door is always open and the team leaders. We have good communication. I’m really happy there” and “We have a good team; they support each other I’m quite happy working here. I get all the support I need.” The registered manager ensured staff with protected characteristics were supported with any reasonable adjustments if required.

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. The provider had systems in place to check the quality of the service. Audits had been carried out. There were monthly audits of infection control, care plans, mealtimes, activities, observations of care, people’s satisfaction, medicines, call bells, falls, health and safety, and pressure wound prevention. The registered manager carried out occasional unannounced night time checks. The provider carried out regular visits to the service.

The audits were not always robust enough to highlight and manage shortfalls in the service. For example, audits of staff files had not detected issues with missing information, medicines audits had not identified the medicines concerns, infection control audits had not picked up the areas we found required attention.

There had been a lack of management oversight of constipation risks relating to people as systems were not always in place to review bowel charts regularly. This had led to people not receiving medicines and help in a timely manner to relieve constipation. The registered manager acknowledged that audits were not always robust. They made amendments to the audit tools after we identified issues to ensure more robust audits were completed in the future.

Services providing health and social care to people are required to inform the CQC of important events that happen in the service. This is so we can check that appropriate action has been taken. We were assured that all incidents had been appropriately reported. People's personal records were stored securely including on computers and applications on devices. These were protected by passwords, so that only staff who had been authorised to access the information could do so. The provider had displayed their last inspection rating on their website and within the building.

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 had developed partnerships with varied organisations and the local community through activities, end of life care, the local authority and through good links with the home visiting team and GP. The registered manager told us about partnerships with other local services where they had developed support networks with other registered managers. They worked with other local homes to book and arrange activities (such as visiting ponies) which enabled multiple visits to local care homes on the same day to keep costs down.

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 registered manager told us they had reviewed the feedback we gave them as part of the onsite and offsite assessment process and valued this. They were using the feedback to make improvements to the service and to put systems in place to embed the changes. Areas discussed at the assessment site visit were added to the action plan for the organisation in a timely manner and the registered manager updated CQC on the progress of these actions. After the assessment they confirmed these actions had taken place.