Lark View Care 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. This is the first assessment for this newly registered service. This key question has been rated 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 of people's challenges and needs and their communities' needs. The provider had a clear vision of the culture they wanted to promote within the service, including, and respectful. The service had its own mission statement and philosophy included, ‘To provide the highest standard of care which places the individual at the very centre of everything we do.’ The values are introduced during the staff induction process.

The registered manager understood their role to promote the values and culture within the service. They described how they ask questions during interviews to assess the applicant’s attitude and ensure it aligns with the service's vision. The values are displayed around the service.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment, and support, and who 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 registered manager had worked at all levels within the care sector and worked as the registered manager in another of the provider's services before moving to Lark View Care Home. The registered manager was keen to give staff within the service the same support and opportunities which staff had confirmed during the assessment.

People told us they knew who the registered manager was and saw them regularly. Both people and relatives told us they were comfortable raising any concerns they may have with the registered manager.

The provider fostered a positive culture in which people felt they could speak up and have their voices heard. Staff told us they were confident to raise concerns with the registered manager and that action would be taken. The registered manager described a situation in which staff had reported poor practice, which they had investigated and dealt with.

Staff told us the registered manager was approachable and very good at listening to staff and their concerns. Staff attended regular meetings where concerns were discussed and the actions staff needed to take were outlined. Following each meeting an action plan was put in place and updated at the next meeting.

The provider demonstrated a strong commitment to diversity within the workforce and actively fostered an inclusive, fair culture. They promoted equality and equity through clear policies designed to support all staff. Several staff members told us they had been encouraged by the registered manager to explore senior roles, particularly when they had expressed concerns about balancing work and personal responsibilities. Staff felt confident that opportunities for development were available to everyone, regardless of their current position, and that progression was achievable. The registered manager also committed to supporting all staff who wished to complete a Level 3 Diploma in Care, ensuring access to further professional development.

The provider did not have effective systems of governance or clear lines of accountability. Roles and responsibilities were inconsistently understood, and oversight arrangements were not robust. As a result, leaders did not consistently act on reliable information about risk, performance or outcomes, and information was not always shared appropriately or securely with relevant partners.

Although the registered manager recognised that significant improvements were required, the actions taken to address these shortfalls were not sufficient. A service improvement plan had been developed following the October quality audit, but this plan did not identify several of the serious issues found during this assessment. Where actions had been allocated, they lacked sufficient detail or effective monitoring.

The improvement plan stated that care plans and risk assessments were not consistently reviewed in response to changes in people’s needs. While the progress report claimed these reviews had been completed, it failed to address the quality of those reviews. During this assessment we found ongoing concerns with the accuracy, completeness and clinical relevance of care planning documentation, demonstrating the reviews had not been effective.

Medication audits had highlighted some issues, such as failures to record fridge temperatures, which had been rectified. However, the audit processes did not identify more significant shortfalls identified during this assessment, including failures in the system for ordering monthly medicines. This demonstrated that audit systems were not reliable or comprehensive.

The improvement plan acknowledged that audits of recruitment files had not been undertaken. However, at the time of this assessment, no action had been taken to implement these audits, and we found shortfalls in safe recruitment practice. As a result, we could not be assured that new staff were being recruited safely or in line with regulatory requirements.

Shortfalls in the recording of capacity assessments and best interest decisions had also been identified previously. The progress report stated that the capacity sections of people’s care plans would be reviewed, but there was no evidence of ongoing monitoring or staff training to ensure they understood their responsibilities under the Mental Capacity Act. There was no assurance that staff completing care plans had the necessary skills and knowledge to assess capacity or record best interest decisions appropriately.

Overall, the provider’s governance arrangements were not effective in identifying, addressing or preventing risks. Failures were repeated, not fully understood, and not acted on in a timely or competent manner. This placed people at risk of harm and demonstrated a systemic lack of oversight and leadership.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners or collaborate for improvement. The service supported people living with dementia in attending groups in the wider community including external day services.

Staff were involved in wider partnership working, some elements of collaborative practice were still taking place. People had been referred to health professionals as needed, and relatives had been informed of the support people were receiving.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways to deliver equality of experience, outcomes, and quality of life for people. The registered manager had focused on making improvements since joining the service, but further improvements were needed. There was a service improvement plan in place, but this did not include how to maintain the improvements once made.

The registered manager was aware of some of the technology available but had not considered this when people’s needs changed, such as sound monitors in people’s rooms during the night.