Luke's Place

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 inspection under the previous provider, we rated this key question inadequate. 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.

At our last inspection under the previous provider, we found a breach of regulation in good governance. At this inspection we found that the breach has been met.

This service scored 68 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a clear vision and values that were understood by staff. Leadership was visible, approachable, and committed to continuous improvement. The provider had demonstrated a positive, compassionate, listening culture that promoted trust and understanding between them and people using the service. The culture was focused on facilitating mutual trust between leaders and staff as well as learning and improvement. Leaders continued to have discussion with staff through meetings, supervisions and day to day observations where they ensured staff understood the values and direction the provider set out. Staff and managers gave positive feedback about this initiative.

The service was managed by a leader who had a clear focus on delivering person-centred care. Leaders promoted a positive and inclusive culture where people and staff felt valued and supported. A staff member said, “[Registered Manager’s] dedication extends beyond me - they foster a culture where every team member feels respected and valued, regardless of background or neurodiversity. Their compassion and advocacy have not only enabled me to thrive but have set a standard for inclusivity throughout our service.”

People and staff were regularly asked for feedback, which was used to shape service delivery. The provider encouraged relatives to attend meetings where their voice could be heard and to share their views about how to make change either within the service or to enrich the lives of individuals.

The staff understood what to do if they needed to speak to someone about their concerns. The provider had a whistle blowing procedure in place.

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.

Staff felt supported and valued in their roles. There was a strong team culture and a shared commitment to person-centred care. A staff member said, “The provider does well in fostering a supportive environment, encouraging professional development, and promoting person‑centred care. Continued improvements could focus on communication, staffing, and opportunities for hands-on skill development.”

The provider did not always have clear responsibilities, roles, systems of accountability and good governance. The provider had a governance system, however it lacked oversight of certain aspects of the care and care records being completed for people using the service. As part of the inspection, we had identified areas of improvement, which had not been found as part of their governance systems. For example, staff not following guidance set out in the risk assessment.

The management team completed regular audits; however, where improvements had been identified, there was not always clear action plans or evidence to show actions were embedded in the service.

The management team started to capture lessons learnt and shared these with staff. However, we found examples where lessons learnt, and actions had been identified but no evidence that these had been shared with the wider team. This meant staff would not always be equipped with the knowledge to change their support practice for the better.

Prior to the inspection the provider had identified there needed to be a review of the governance systems to ensure the audits completed were meaningful and actions identified were captured and embedded in the services.

The Registered Manager 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. A professional said, “My interactions with [Registered Manager] have always been very productive, and I truly feel that them and [Manager] are extremely helpful and dedicated to those they support.”

The provider had established strong links with the local community. They offered access to their facilities, including a hydrotherapy pool, to local people who required this to support their health and wellbeing.

The provider did not always focus 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. However, where actions had been identified through some of the audits these were not always captured and so there were not clear evidence that improvements were made and embedded.