Lilias Gillies House

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• 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

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 service management and leadership were inconsistent. Leaders and the culture they created did not always support the delivery of highest-quality care.

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

The service 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.

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. Therapy staff were able to describe their approach and what was delivered to clients at the service. Staff had an opportunity to review the visions and values and the strategy for the service in the annual staff away day.

Staff were updated with any changes to policies and procedures in the weekly staff business meetings.

Staff told us they felt supported by their direct peers and enjoyed working with them. They said they often observed the clinical staff meeting the values of the service in their interactions with clients.

There were some areas of service improvement and safety that had not been identified and managed well by leaders. The service had not effectively managed to maintain a safe environment for all residents.

Staff and residents said that leaders were visible in the service and approachable for residents and staff. Staff said that they felt supported by managers and senior managers.

Staff received training on whistleblowing and bullying and harassment as part of their annual mandatory training.

Staff said they felt confident to raise concerns and could do so in the weekly staff business meetings.

Residents were involved in decision-making about changes to the service. They were asked if they wished to be part of the interview panel when interviewing new staff. However, managers recognised that the process for obtaining feedback from residents could be further improved.

Residents could meet with the provider’s senior leadership team to give feedback. The service held annual barbeques which residents and staff attended.

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

Staff were able to apply to work flexibly to account for personal circumstances such as caring responsibilities and health issues.

The service had a diverse workforce which was reflective of the local community.

Managers put reasonable adjustments in place for staff members to help them carry out their role such as a phased return to work.

The service 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.

Our inspection identified several areas of improvement and some serious concerns that the service had not identified themselves through their own governance processes. For example, the recording and management of environmental risks relating to general safety as well as individual resident risks.

Although there was a clear framework about what should be discussed at monthly managers meeting, these meetings had not taken place since December 2025. The service informed us this was due to staff sickness and staff changes during that time. Managers did not have oversight of the latest data for the service, we were unable to see the latest supervision, annual appraisal and mandatory training rates (including agency staff) from December 2025 until March 2026. This was identified as an area to improve on in the action plan sent to us after our visit.

We did not see evidence of analysis of trends and themes from incidents, audits and complaints over the last 12 months, including learning and outcomes from complaints and incidents. After the inspection, the provider told us that they were reviewing and rebuilding their organisational governance framework.

We could not see that all information about the quality and care of the service was fed into the weekly staff business meetings, such as oversight of audits.

Not all staff had access to the equipment and information technology needed to do their work as agency staff did not have access to the resident’s electronic record system. They told us that each resident’s care and support needs were discussed with them upon their induction and any changes were discussed in the daily handover.

The service did have a risk register and a business continuity plan in place to cover a range of emergencies.

The service did not always understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not always share information with partners.

Senior leaders had engaged with external stakeholders such as commissioners and established links with local substance misuse services, but care records did not demonstrate clear communications and updates between therapeutic practitioners and a residents community care team. This was a responsibility outlined in the staff handbook, aiming to ensure that community care teams are kept updated on the resident’s progress as well as any concerns. We could not see this demonstrated in the 3 records we looked at.

The service did not always ensure that robust learning, outcomes and improvements were in place to measure how the service had improved over time.

Staff completed monthly audits including reviewing the environment, health and safety, Infection prevention and control, medicines and care records but the environmental and medicine audits did not have oversight of all the essential information required to ensure that safe and quality care was being provided. The environmental audit did not include checks of fire extinguishers. The medicine audit did not have oversight of controlled drugs and Medicine administration records (MAR). Three audits had also not been completed since January 2026. We were told that this is the responsibility of the team leader who was currently away from work, this task was not delegated to another staff member whilst they were on leave. We could only see evidence of the medicine and records audits being reviewed in the monthly management meetings, it was not clear how learning from audits was shared with the staff team.

The service had become an accredited Assessed and Supported Year in Employment (ASYE) provider to support newly qualified social workers by aiding their professional development in this sector