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 inadequate. 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 62 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The culture within the service had improved significantly since the previous assessment. Generally, staff told us there had been positive changes under the current leadership team and described a more supportive and open working environment. There continued to be challenges as some changes in staff roles and shift patterns continued to be introduced to enhance the quality of service to people. The provider was completing the work in a fair and transparent way, accommodating staff anxieties where possible.
People, relatives and staff spoke positively about the registered manager and wider management team and told us leaders were more visible, approachable and engaged in the day-to-day running of the service. A relative told us, “It has definitely improved, they have been exceptionally good. A big improvement is (registered manager) is approachable, listens and makes changes, she knows names and appears on the floor. Before, there was a lack of management, and everyone thought they were the manager.”
Leaders had developed a clearer direction for the service with a strong focus on improving outcomes for people. Staff understood the priorities for improvement and generally felt part of the process. A staff member said, “I do feel supported by the unit managers and (registered manager). She is the right fit. I feel comfortable with her, she listens and has time. She is firm but fair and we will have a laugh with her.” Whilst improvement work remained ongoing, there was evidence a more positive culture had been established and was continuing to develop across the service.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Lavender Fields now benefitted from a stable registered manager and revised management structure following a prolonged period of leadership instability identified at the previous assessment. Staff, relatives and people using the service described leaders as approachable, supportive and visible within the home. Relatives’ comments included, “At the weekend they do now have a manager and senior, that’s definitely an improvement”, “(Registered manager) is quite visible. She’s not locked away in her office. I feel if she’s there, I can go and see her anytime”, “She’s good and I hope she stays” and “We like having a manager on the separate floors, that’s good. It makes sense.”
Leaders demonstrated a good understanding of the challenges the service had faced. They were able to clearly describe the action they had taken to lead improvements to increased quality and safety. The introduction of unit managers based on each floor had strengthened operational oversight and provided staff with improved access to support and guidance.
Leaders worked constructively with healthcare professionals and external partners and had prioritised improving the experience and outcomes of people living at the service.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff told us they felt able to raise concerns and seek support from managers. The registered manager was frequently described as having an open-door approach, and staff reported they were listened to and taken seriously when concerns were identified.
People and relatives told us they knew who to speak with if they wished to raise concerns and felt more confident concerns would be acted upon than previously. Leaders sought feedback through meetings, discussions and ongoing engagement with staff, people and relatives. Although the service continued to embed new leadership arrangements, the overall feedback demonstrated a culture where staff generally felt able to speak up and have their views heard.

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.

The provider worked towards creating an inclusive workforce and employed staff from diverse backgrounds. Staff told us they felt supported by managers and described a more positive culture than had previously existed within the service. The provider had invested in staff development and training and compliance in equality, diversity and inclusion training was high. We did not identify evidence that staff were disadvantaged or excluded within the workplace and managers promoted an open and supportive culture.

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.

Governance arrangements had improved but were still not effective in fully identifying and addressing concerns. There was evidence leaders were actively identifying issues and taking action to improve the service. However, monitoring and auditing systems were not consistently effective in identifying and addressing all quality and safety concerns. Medicines management concerns, inconsistencies in Mental Capacity Act practice and the variation in the quality of care planning and risk assessment had not always been identified through existing auditing processes. We found some audits focused on whether documentation was present rather than the quality and effectiveness of the information recorded. Where actions had been identified, there was not always clear evidence they had been tracked, completed and embedded. Governance arrangements required further development to ensure systems were robust and fully effective in assessing, monitoring and improving the quality and safety of 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 management team now engaged well with external partners such as GPs, district nurses and other specialist services to ensure people had access to the care they needed. Families described improved communication and told us they felt more involved in discussions about care and support. People were encouraged and supported to maintain relationships, community links and faith-based activities that were important to them, promoting wellbeing by maintaining meaningful connections.
Leaders demonstrated a willingness to work with partners to improve outcomes for people. The registered manager was involved in various local community groups and forums to share experiences and gain external support. These included, local authority provider forums, Skills for Care groups and registered manager networks. These partnerships supported an outward focus to benefit the overall care and support of people.

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, outcome and quality of life for people.

Improvements were evident in care planning, safeguarding processes, staff training, leadership visibility and healthcare engagement. Systems were in place to review incidents, undertake audits and monitor performance. However, approaches to learning and continuous improvement were not yet robust and fully embedded. Although incidents and safeguarding concerns were recorded and reviewed, evidence of trend analysis, service-wide learning and the consistent implementation of improvements was sometimes limited. Some audit records contained inconsistencies and quality assurance systems did not always demonstrate how identified concerns had resulted in sustained improvement.
While leaders clearly understood the areas requiring further development and were actively working to address them, additional work was needed to evidence a fully embedded culture of learning, quality improvement and continuous oversight.