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 inadequate. At this assessment the rating has remained 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 good governance. The provider had not always ensured their systems were effective or ensured oversight of quality, safety and management of risks. There had been a lack of improvement at the service since our last inspection.

This service scored 29 (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 did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

The culture at the service continued to not be positive. Staff did not feel well supported by the provider and were not aware of any shared visions or strategies they had to help people have the best quality of care they could. Staff were not being supported to be the best they could be in their jobs and increase the opportunities for people to have good experiences. Our findings in multiple areas at this inspection as discussed through the report led to a negative culture and poor experiences for people. The provider had not sufficiently addressed the issues we found in relation to the direction and culture at the service during our last inspection. People continued to be at risk of less good outcomes and experiences as a result.

However, people and relatives remained positive about their care. One person said, ‘‘I really like living here. It is good.’’ A relative told us, ‘‘All in all I have had really good experiences with the service and staff are very loving and caring towards not only [family member] but also to me.’’

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

Since our last inspection there had been several changes in the manager of the service. The provider’s managers had started to implement audits and measures to identify and drive improvements at the service. However, these had not been effective and in some cases, the management team had not acted on improvements when they knew they were needed. For example, updating care plans or making sure staff had the training they needed to support people safely. The management team were unaware and did not have knowledge in areas such as whether staff had training and competency checks completed or whether care plans were up to date.

We continued to see no evidence of audits completed at provider level. Just before our inspection began the provider had hired support from external consultants to support with audits. These audits were just beginning to be put in place at the time we started our inspection. This meant since our last inspection very little effective audits had been completed to identify risks, monitor or take action to improve the service. We could not be assured leaders were capable in their job roles as a result of these findings.

Staff did not feel leaders were compassionate or inclusive. They told us they were not listened to and were treated poorly if they tried to speak up at the service. Staff were more positive about the support they had from the most recent manager of the service who was no longer in post.

People and relatives told us they felt the management team and provider were kind and caring. One person said, ‘‘[Manager] is lovely. Always there for us.’’ A relative told us, ‘‘There needs to be some consideration given to how hard [management team] work. They take on people who are more difficult to support and do their best to give them the best life possible.’

Staff did not feel they could speak up and that their voice would be heard. They told if they did speak up or raise concerns, they were given warnings or would not be paid in a fair and easy manner. There was evidence around the service for example, that if staff did not perform their duties their pay would be affected. We received mixed feedback from relatives about how they felt about speaking up. One relative said, ‘‘I do not speak up as I get worried [family member] may get treated differently.’’

However, information about how to speak up was readily available for people, relatives and staff. People approached staff and asked them for support with no concerns. A relative told us, ‘‘There have been a few bits I speak up about, and changes always happen quickly.’’

The provider did not value diversity in their workforce. They did not work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff told us they did not feel well supported at work. They told us when they made a mistake or spoke up about how they felt things could be improved, this often resulted in negative consequences. Staff told us the provider, and some members of the management team spoke with them unkindly. Posters around the service informed staff they would not be paid in a fair and equitable manner if they did not perform their duties. We could not be sure staff were being supported to regularly discuss their job roles and any support they may need.

The provider had changed this poor practice and recently stopped paying staff by cheque if they made a mistake and staff told us this had made them feel better about working for the provider.

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

Since our last inspection an action plan was put in place by the provider to address the issues we found. However, there remained very few meaningful audits being completed to effectively govern and monitor the quality of the service. Where audits had been completed actions had not been taken, meaning the audits were not effective. Specific audits in areas such as monitoring people’s food and fluid intake, people’s care and support experience or staff training and knowledge were not in place. The manager was unsure where many aspects of governance such as audits and records were kept at the service. As a result, we did not see some key pieces of evidence we asked to see or had to wait extended periods of time for information to be located. This meant governance systems were not effectively organised and made it difficult to be assured governance measures were in place to effectively monitor the quality of the service.

The external consultancy company were confident they would be able to implement audits to effectively monitor the service. They sent us some evidence of these. However, we could not be assured the service had been effectively governed since our last inspection.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Due to the lack of audits of areas of the service such as people’s care records we could not be assured professionals would always be contacted in a timely manner if people needed this support. People continued to have less opportunities to access their local community than what the provider and staff team wanted, although this was an area that continued to be focused on.

However, we saw evidence staff did contact and work well with professionals such as GPs. The provider had worked well with the local authority since our last inspection to try and identify and drive improvements. One person told us, ‘‘I see the GP when the staff organise it for me.’’ A relative said, ‘‘I have no concerns that staff would seek support from health professionals if [family member] needed this.’’

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people.

After our last inspection, the provider put a comprehensive action plan in place to address the issues we found. Many of these actions such as staff competency and care plan reviews were signed off as completed. However, our findings at this inspection showed this not to be the case. Whilst there had been some small improvements at the service, these were not significant. We still found areas for improvement in the majority of areas we had concerns about at our last inspection. The service remains in breach of multiple regulations as at our last inspection.

There had been very little improvement at the service since our last inspection 7 months ago. We could not be assured the provider and management team were going to be able to effectively drive and implement necessary improvements at the service to ensure people received good quality care that met their individual needs.