Lincoln Road

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 this key question was rated 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 the 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 implement a positive and embedded shared vision, strategy and culture that was based on national policy and best practice.

As reported on throughout this report, improvements were needed to ensure the right support, right care, right culture guidance was always considered and implemented to ensure people were involved with all aspects of their care.

However, the management team told us about their direction and culture of the service, sharing with us, they got on well as a team and they were always striving to improve. Staff told us they felt supported and that the culture they worked within was positive.

Not all leaders understood the context in which the provider delivered care, treatment and support.

There was no registered manager in place, the registered manager had recently left the home, and the provider told us they were in the process of recruiting to this position. This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. There had been 3 registered managers at the home since 2024 which had impacted on the consistency of how the service was managed.

The lack of effective systems and oversight of the care people received demonstrated a lack of capability within the management and leadership team. There was also a lack of understanding from the management team about the right support, right care, and right culture guidance which placed people at risk of receiving unsuitable care which failed to promote their human rights, independence and choice.

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

There was a whistleblowing policy in place. Staff we spoke with were aware of these procedures and the action they needed to take if they had concerns.

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

Staff were happy working at the service and felt they were treated fairly. There were procedures in place to consider staffs’ individual needs and ensure all staff were treated equitably.

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

Some audits were in place; however, they were not effective in keeping people safe, identifying concerns and driving improvements through the service. For example, the medicines audit had failed to identify that key information in as required protocols was not always available.

Care plan reviews and audits had not identified care plans were not always in place when needed or where further improvements were needed. We saw a tracker had been introduced to show care plans were ‘missing’; however there was no detail about what these were or who they related to, in addition, the due date for this had passed on 15 June 2026. The systems to manage training in the home had not identified some staff had not received specific training relating to someone’s health and they had failed to ensure the principles of the Mental Capacity Act (2005) were followed.

The provider did not fully understand their duty to collaborate and work in partnership, so services work seamlessly for people.

There were systems in place to ensure the provider worked in partnership with other agencies. As part of this assessment, we asked the Local Authority for feedback, they shared with us a list of concerns they had identified in the last 6 months at the service. The provider shared with us an audit the Local Authority had completed in 2024, this showed the provider had not always completed the actions that had been identified. For example, the audit identified ‘Unable to see evidence of face-to-face training manual handling of people at time of visit as face-to-face training matrix is kept at head office’. At our inspection we found the same concerns.

The provider did not always focus on continuous learning, innovation and improvement across the organisation.

The systems in place were not effective and had not identified all concerns as reported upon, or driven improvements, which meant learning opportunities were missed. For example, the systems in place had not identified incident and accident forms were not being used to inform reviews of people’s care, and they had not identified when safeguarding concerns should be investigated or reported.