Lucketts Farm

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 good. At this assessment 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 legal regulation in relation to good governance.

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 did not have a clear shared vision, strategy and culture which was 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 provider did not have effective systems in place to mitigate the risk of a closed culture within the service. A closed culture means a poor culture that can lead to harm, which can include human rights breaches such as abuse.The provider had not prioritised safe, high quality and compassionate care. Effective systems were not in place to review the care people received, for example risks to people’s health had not been recognised or prioritised.

Though we saw some positive examples of people being supported with kindness and supported to take part in daily life in a way that worked for them, there was lack of consistent planning for how the service would support independence and engage with people and their loved ones to ensure they were involved in their care. There were no clear processes for promoting care that promoted people’s rights, or was in line with best practice for a service supporting individuals with a learning disability or who were autistic.

Leaders did not understand the context in which the provider delivered care, treatment and support. They did not embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

Management did not have a clear understanding of statutory guidance such as RSRCRC that we expect to demonstrate they are complying with, to ensure people have access to care that promotes independence, choice and human rights. There were no clear plans in place for how the service would support people in being independent, and having the same quality of life that most people take for granted. Though they were responsive to areas of concern where we identified them, they had not identified that restrictions in people’s own homes did not ensure people’s privacy or rights as individuals. The provider was not up to date with best practice expectation for empowering people with learning disabilities or were autistic to live life in the way they wanted to, always had choice and freedom or were supported with positive risk taking.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff we spoke to were confident that they could raise any concerns and that these would be listened to and investigated. One staff member told us, “…Communication is now better, management talk to staff and there are regular supervisions which means much greater clarity and support”. There were regular staff meetings which we saw evidence of staff raising concerns about people they supported, and that these were discussed in depth with clear actions agreed based on staff feedback. However, we identified that there were a number of areas where people were not being managed safely, or in a way that maximised their independence or freedom. This has not been identified or challenged, so we could not be assured that staff had an appropriate level of understanding of how care should be being delivered to be able to know when it was not being delivered or to speak up.

The provider did not always value diversity in their workforce. They had not worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. All staff had completed training in equality and diversity, and staff explained to us that they were always able to take time away from work if needed due to personal or family circumstances. There were regular supervisions to check if when staff on any challenges they were experiencing, and if there was any additional support that could be provided. One staff member told us “There is always somebody available to speak to if needed, and management are supportive”. However, the provider had failed to recognise that all staff had an equal right to safe working conditions which we found were not being respected for the majority of staff who were expected to work unsafe numbers of hours. Staff often worked on their own and were responsible for safely managing complex health and support needs, and were exposed to a high risk of harm through lack of appropriate rest or effective guidance.

The provider did not 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. There were regular checks in place which covered staff competency, infection prevention, medications, incidents and accidents and feedback from people, relatives and staff. However, these were not effective in identifying areas where people were being exposed to a risk of harm or not being supported in line with the least restrictive approach. People’s care plans were reviewed every 6 months but management had not identified that these lacked crucial detail, people’s health needs were not risk assessed and that there was insufficient information for staff to understand how to achieve their goals and ambitions. Where incidents had occurred, records were not detailed enough to show what action or learning had been taking, and how the service would work to prevent incidents occurring again in the future. There had been a failure to monitoring staffing levels to ensure they could safely meet peoples need, or that the service kept up to date with best practice guidance for supporting people to live with maximum independence or choice. Management acknowledged that monitoring had not always been effective, and a planned switch to a digital care record system aimed to ensure they had a live overview of the care being delivered across the service.

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. We heard some positive examples of collaborative working with external bodies to support people. For example, they had worked with the local diabetes team to train care staff to be able to be safe and competent to administer insulin for 1 person, which had allowed continuity of care as this person could be supported their usual carers who knew them well. One staff member explained, “We regularly talk to the nurses about (persons name)’s diabetes if we have any concerns, to make sure we are supporting them safely”

However, people did not always have care plans in place to effectively or safely manage their health conditions. This meant it was not clear what care people were supposed to receive, or at what point the service should make referrals to external professionals.

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.

There were regular staff meetings in place which focused on people’s health needs and any areas where people were being exposed to a risk of harm and saw collaborative discussions exploring how staff could make changes to support people. However there no consistent process for ensuring that clear actions, learning and analysis of themes and trends were taken when incidents or accidents occurred. There were significant areas where people’s health conditions were not being managed safely or being supported in the least restrictive way. These had not been identified demonstrating people’s care needs were not being effectively monitored to drive clear improvement or care based on current evidence and people’s human rights., however further work was needed to ensure that clear actions, learning and analysis of themes and trends were taken where incidents and accidents occurred.