Lawnbrook 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.

At our last assessment we rated this key question good. At this assessment the rating has changed to 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 54 (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 always have a shared vision, strategy and culture that was consistently understood and embedded across the service.

Leaders described a clear set of values which placed people at the centre of their care. The registered manager spoke about promoting dignity, respect and independence, and demonstrated a commitment to delivering person-centred care.

We saw some examples of these values being reflected in practice. People were supported to personalise their bedrooms and were involved in decisions about their environment, which helped promote independence and choice.

However, feedback from staff demonstrated this culture was not always experienced consistently. Some staff told us they did not always feel supported and raised concerns about fairness and consistency in management approaches. This meant values were not always embedded across the staff team.

The provider had recognised the need to strengthen leadership and had introduced additional support to help develop the registered manager and improve consistency in staff management.

Overall, while leaders promoted positive values, these were not yet fully embedded in practice to ensure a consistent and positive culture across the service.

Leaders were not always capable, compassionate and inclusive in the way they led and managed the service.

The registered manager demonstrated a commitment to providing person-centred care and spoke positively about promoting dignity, respect and inclusion. However, we identified gaps in their understanding of key areas of practice, including the Mental Capacity Act (MCA) and best interests decision-making, which are essential to ensuring people’s rights are upheld. The registered manager was committed to improvement and was developing in their leadership role, with support in place at the time of the assessment to strengthen their knowledge and oversight.

The provider had recognised the need to further strengthen leadership skills and had introduced additional support, including mentoring from an experienced manager. The registered manager was also undertaking further training to develop their knowledge and skills in managing the service.

People and their relatives were generally positive about the registered manager. They described them as approachable, supportive and easy to speak to, and told us they felt able to raise concerns if needed.

Overall, while leaders demonstrated a positive and open approach and were developing in their roles, leadership capability was not yet consistently established to ensure effective oversight and support across the service.

The provider did not always ensure there was a positive culture where staff felt able to speak up and share concerns.

The provider had policies and procedures in place to support staff to raise concerns, including access to senior leaders. Senior leaders visited the service regularly and engaged with staff and people during visits and audits.

Feedback from staff about speaking up was mixed. Some staff told us they felt comfortable raising concerns and described managers and senior leaders as approachable. However, other staff told us they did not always feel confident to speak up or that their concerns would be addressed consistently. They told us they did not always feel supported and raised concerns about how issues were managed. This meant that leaders had not fully embedded a culture where staff felt able to speak up.

The provider had recognised the need to strengthen leadership and oversight and had introduced additional support. While this support was in place, it had not yet ensured staff consistently felt confident to raise concerns.

Overall, while systems and leadership support were in place, these were not yet fully effective in creating a consistently open and supportive culture where staff felt able to speak up.

The provider did not always ensure an inclusive culture where all staff felt treated equally and supported.

The provider had policies and procedures in place to promote equality, diversity and inclusion within the workplace. These included arrangements to support staff wellbeing, such as flexible working options, and were in line with relevant legislation.

Feedback from staff was mixed. Some staff told us leaders promoted values of dignity, respect, and inclusion, and that they felt supported and treated fairly in their roles. However, others raised concerns about fairness and consistency in management approaches and said they did not always feel equally supported. This meant that equality, diversity and inclusion were not consistently experienced across the staff team.

The registered manager was committed and passionate about their role, and the provider had confidence in their leadership. Additional measures had been introduced to support their development and strengthen leadership capacity.

Overall, while systems and policies were in place to promote equality, diversity and inclusion, these were not yet fully effective in ensuring all staff experienced a fair, inclusive, and supportive working environment.

The provider did not always 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.

The provider had not always established effective systems and processes to assess, monitor and improve the quality and safety of the service. This included systems to identify, assess and mitigate risks to people’s safety.

Systems were in place to monitor quality, including audits and oversight processes. However, these were not always effective in identifying all areas of concern, mitigating risks, or recognising the extent of the shortfalls identified during our assessment.

For example, audits had not identified gaps in areas such as financial oversight, recruitment records and fire safety monitoring. This meant the provider could not be assured that all risks were being effectively identified, monitored and managed.

Systems to monitor staffing arrangements were also not fully effective. Staffing rotas did not clearly distinguish between contracted hours and additional shifts. This lack of clarity reduced the provider’s ability to effectively oversee staffing deployment and review patterns of shift allocation. Some staff told us they felt weekend and additional shifts were not always distributed fairly; however, due to limitations in the rota records, we were unable to fully verify these concerns or establish whether shifts had been allocated equitably.This meant the provider could not effectively review or evidence whether shifts were allocated fairly or consistently.

The service demonstrated a commitment to quality improvement. Leaders acknowledged that improvements were underway and showed a willingness to drive change. They were responsive to feedback and began taking action to address concerns during the assessment.

Overall, while systems were in place, these were not consistently effective in identifying and managing risks, providing robust oversight, or ensuring sustained improvements across the service.

The provider 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.

The service had established positive working relationships with a range of health and social care professionals. Professionals told us staff were approachable, responsive and worked well with them to meet people’s needs. They described the service as welcoming and collaborative, and said they felt confident working alongside staff.

Professionals described communication as effective, clear and timely. They told us staff listened to advice and took appropriate action when concerns or changes in people’s needs were identified. One professional shared how the service had responded appropriately to a concern they had raised, demonstrating openness and a willingness to improve.

The service worked effectively with external partners to support continuity of care. This meant people benefited from coordinated and joined-up care, with effective collaboration between the service and other professionals.

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 of delivering equality of experience, outcomes and quality of life for people. They did not always actively contribute to safe, effective practice and learning.

Leaders spoke positively about the importance of continuous learning and improvement and described a strong ethos to drive improvements within the service. They demonstrated an awareness of areas requiring development and shared plans to improve outcomes for people.

However, systems to support learning and improvement were not consistently effective in identifying and responding to areas for development in a timely way. Shortfalls identified during the assessment had not always been recognised through existing processes, which meant opportunities for earlier learning and improvement had been missed.

The registered manager and provider were open, engaged and responsive throughout the assessment. They began taking action to address the concerns identified during the assessment. This included implementing an action plan to support improvement. However, these improvements were at an early stage, and time was required for changes to be fully implemented, embedded and to demonstrate sustained impact in practice.