Lilias Gillies House

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 was inconsistent. Leaders and the culture they created did not always support the delivery of highest-quality care.

Governance systems were not always effective in identifying learning and areas for improvement. There was limited evidence that staff collected and analysed data about outcomes and performance to identify themes and improvements, and monthly meetings had not been taking place consistently.

However, we did identify areas of good practice. Staff knew and understood the provider’s vision and values and how they applied to the work of their team. Staff said they felt respected, supported and valued. Therapy staff were able to describe their approach and what was delivered to clients at the service.

The organisation had recognised that there were some areas that needed addressing and improving and had taken steps to respond to this. After the inspection, we were informed that the provider had commissioned a review of the service and admissions to the service were paused, whilst the service stabilised.

Overall, the service could not demonstrate effective systems to assess, monitor and improve the quality and safety of the service, resulting in a breach of Regulation 17 (Good governance).