Lillibet House

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 we rated this key question requires improvement. At this inspection the rating has changed to Inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of the legal regulation in relation to governance and reporting notifications to CQC. The provider had not always ensured their systems were effective or ensured oversight of quality, safety and management of risks. The provider was not making sure notifiable incidents to CQC were being identified and reported.

This service scored 36 (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 and registered manager did not have a shared vision, strategy and culture. The culture at the service was not always positive as a result. The provider and registered manager told us they wanted people living at the service to have good quality care and that treating them in a person-centred way with dignity and respect was the main aim of the service. However, our findings in relation to people being safeguarded from abuse, staff not having the training or competency to support people and people not always being supported to identify and follow their preferences, likes and dislikes, showed the culture at the service was not always positive. Staff working at the service did not all feel they were well supported or that they were given the support and enablement they needed to support people to the best of their ability.

However, people and their relatives were positive about the support at the service. One person said, ‘’I like it here and will live here forever.’’ A relative told us, ‘‘I think the [management and staff team] are doing the best job they can, and I would not want [family member] living anywhere else.’’

The provider and management team did not demonstrate they had capable leadership with the right skills and knowledge. We identified breaches of the legal regulations and concerns in the areas of safeguarding, safe care, person centred care, staffing, dignity and respect and governance. Leaders had not independently identified and acted on these concerns prior to our assessment.

The provider was reliant on partners such as CQC and the local authority to visit and let them know where improvements needed to be made. They were not completing audits at provider level to monitor the quality of the service. The registered manager was passionate about the service, however spent a lot of time dealing with daily issues and did not have an effective oversight of the service. The provider and registered manager had not identified the issues we identified during this inspection through their own internal systems and audits. Some staff told us they did not always feel supported by the registered manager or the provider.

However, people and relatives were positive about the kind and caring nature of the registered manager. One person said, ‘‘[Registered manager] is always around and asking if we are okay. Nothing is too much trouble.’’ A relative said, ‘‘[Registered manager] is excellent and has a lot of time for us. We have a good relationship.’’

The provider had not always instilled a positive culture where people and staff felt they could speak up and their voice would be heard. Staff were not reporting safeguarding concerns in a timely manner. Some staff told us they had raised issues with the registered manager and provider but that these issues had not been considered. People who did not find it easy or were unable to communicate verbally were not being given regular opportunities to feedback about the service.

However, there were policies in place to support people and staff to speak up if needed. A relative said, ‘‘We have never had the need to raise any concerns but if we did, I know they would be sorted out straight away.’’

The feedback we received from staff and our findings during this inspection indicated that there was an increased risk that leaders had not provided sufficient leadership, direction, and guidance for staff to come together for the common purpose of supporting people with safe, effective, caring, responsive, and well-led care were workforce equality, diversity and inclusion was always promoted and well managed to achieve this. Not all staff felt well supported or listened to in their job roles.

However, some staff told us they enjoyed their roles at the service and felt well supported. The providers recruitment process was fair and equitable.

The provider did not have clear responsibilities, roles, systems of accountability or good governance. Whilst some audits were being completed at the service, these were not effective in identifying areas where improvements could be made. The providers internal audits and governance had not identified or started to address the issues we found during this inspection. For example, in areas of safeguarding concerns not being reported effectively, care plans and daily records not being reviewed, staff training and competencies not being completed and people not receiving person centred care. This meant governance measures at the service were not effective.

The registered manager was completing some audits that were effective in areas such as health and safety of the building and equipment. However, they were not supported by the provider or other staff members to help make sure the management of the service was sustainable.

The service did not always demonstrate its understanding of the duty to collaborate and work in partnership, which is crucial for promoting seamless services for people. Whilst staff did make referrals to partners such as health professionals when people needed support, there was a risk this would not happen with the current governing systems at the service. Daily records and care plans were not being reviewed and updated to make sure partners were contacted. People had limited opportunities to access the community, although this was an area the registered manager and provider told us they were looking to improve and invest in. A person said, ‘‘I would like to go out more than I do.’’

Despite our findings, people did see health professionals if this was needed. Visiting professionals were positive about the staff team and how they worked with them. The registered manager worked well with partners such as the local authority. A relative told us, ‘‘We are assured staff will get hold of someone if [family member] needed any help.’’

The provider did not focus on continuous learning, innovation and improvement. We were not shown any improvement plans which focused on learning from findings of audits at the service. The registered manager created an improvement plan during our inspection; however, this was in response to our findings, not the findings of audits completed by them or the provider. During our inspection we needed to give specific guidance to the registered manager and provider to help them understand and start making improvements at the service. The service was in breach of a regulation in safe care and treatment at its last inspection and remained in breach at this inspection. We also found multiple other areas that were not meeting the fundamental standards of care which had not been identified by the provider. This showed a lack of learning and improving at the service.

However, the provider and registered manager did listen to our findings and started to put actions in place following our inspection. A relative said, ‘‘I think [registered manager] wants what’s best and will always strive to be better.’’