Lavender Fields

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 requires improvement.

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 governance at the service and failing to notify the care quality commission of significant events.

This service scored 32 (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.

Staff did not receive regular supervisions or have team meetings to share a vision and strategy that was understood and modelled by staff and the management team. We found no evidence the provider had ensured a shared strategy, culture and values were embedded within the staff team. Staff told us they rarely saw senior management or head office staff, and when they did, they were not reassured they were there to support the staff team or to share knowledge or information. Staff told us there was “a blame culture” and felt that certain members of the team would be “scapegoated” if things went wrong. This demonstrated a lack of clear direction and organisation within the service.

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.

The service had been without a registered manager for more than 600 days at the time of the inspection. A stable and consistent manager had not been in post during this time with multiple interim managers staying for short amounts of time. Feedback in relation to the provider from staff, people and their relatives was generally negative, relaying that senior managers did not engage and had not visited for some time before the inspection, despite the lack of a service manager.

Feedback from relatives included, “I feel I need to go every day to make sure everything is ok, and I know at least one other relative who says the same. When (loved one) first went in I couldn’t praise it highly enough, there was a good manager. Then for more than 2 years there were managers on and off and no leadership and high numbers of agency staff and that’s where it all fell down”.

During our inspection there was a manager in place who had been in post for 3 weeks but in the service for 7 days. Feedback we received in relation to the new manager was generally positive, although guarded as previous experience meant people were unsure, they would stay.

Staff said the new manager had created a positive atmosphere and was, “a breath of fresh air”.

Feedback from relatives included, “I’ve noticed when the interim manager was here and now with (new manager) the atmosphere is much more positive” and “I know the manager, I had a meeting with them the other day, they’re very approachable”.

People did not feel they could speak up and that their voice would be heard. Staff told us they had asked for support, but this was not listened to, and no action was taken by the provider.

Although staff knew how to speak up and who to, they did not feel confident they would be listened to. Staff told us they had raised concerns with the provider previously and no action was taken, leaving staff to carry on as best they could without a manager in post.

Staff told us there were very few visits by the provider during the time they were needed, when a manager was not available, which meant it was not easy to speak with a senior manager. Although staff knew who to go to outside of the organisation, they said they were reluctant to do this as they felt their job may be at risk.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

There was a clear policy of Equality, Diversity and Inclusion and this was evident from the staff base.

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.

The provider did not have a clear oversight of quality and risk in the service which contributed to people being at risk of avoidable harm. The provider had not established or operated systems to monitor and improve the safety and quality of care provision.

Monitoring and auditing processes were ineffective in picking up issues within the service, and the provider’s quality assurance procedures had not been followed by the service or the provider.

In the absence of a registered manager, the provider had failed to make improvements to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users. We found there had been limited identification, assessment or mitigation of individual risks. Staff did not always have guidance in how to manage people’s risks when providing their care.

There had been no oversight by the provider, including their own monitoring systems and audits since July 2024, despite there being no permanent manager in post, leading to a significant deterioration in quality and safety.

There had been no service monitoring of incidents or accidents since December 2024.There had been multiple incidents such as unwitnessed falls leading to significant injury. These had not been identified to enable measures to be put in place to protect people from further injury. We found people continued to have repeated falls with no effective preventative action taken.

Staff were left without support, and a culture had developed where staff were making decisions about people’s care without the training and skills to do so. The provider had significantly failed to identify or taken action to ensure people received safe and good quality care.

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement. The provider did not promote working collaboratively and ensure staff supported people following guidance and support by healthcare professionals and partners.

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. They did not actively contribute to safe, effective practice and research.

A learning culture was not embraced to ensure safety was a priority. Accidents and incidents were not monitored to learn lessons to prevent further occurrences. Safeguarding referrals were not always made in line with local safeguarding protocols, and this had not been identified by the provider. The provider’s response to learning lessons from recurring incidents and lack of action taken to improve outcomes for people was inadequate leading to ongoing risk to people in their care.