House of the Flame Lily

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 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 57 (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 create a positive culture as they were not consistently delivering care in line with the supported living model.

Although the leadership told us there were processes in place to develop a positive culture we could not be assured this was followed or effective. As staff had not received training in key areas [supporting people with a learning disability or autism] it meant staff did not always understand the culture of the service.

As we have identified through this report, our observations, records and the behaviour of staff demonstrated they also did not fully understand the supported living model.

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

The registered manager was not present on the day of the site visit as they were working remotely following a period of absence. The operations manager was unable to share key information with us, so after the inspection we held a virtual meeting with the registered manager to give them the opportunity to provide us with information we required.

A lack of understanding of the importance of delivering an effective model of supported living meant people did not always receive individual care in line with this model of care.

However, people and relatives were happy with how the company was managed and raised no concerns to us.

Care staff were aware of their roles and responsibilities and when they needed to escalate concerns.

The team was aware of and understood their legal responsibilities around notifying CQC about any important events that had happened in the service.

The registered manager contacted us after the inspection and asked us to consider an action plan they had put in place following our inspection, we gave them the opportunity to send this to us. After our site visit the provider sent us an action plan identifying action they were taking following our feedback. We will review this as part of our next inspection.

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

People and relatives knew how to raise concerns and felt confident to do so. Information was available to people in a format they understood.

There was a whistleblowing policy in place and staff were aware of this and the procedures they needed to follow.

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 told us they were happy working within the company and felt they were treated fairly. There were procedures in place to consider staffs’ individual needs and ensuring all staff were treated equitably.

There were not always effective systems in place to make changes and identify areas of improvement.

There were some audits in place however they were not always effective in identifying areas of improvement. There was a system in place to monitor medicines, however it had not identified the concerns with the recording of medicines. The systems in place had failed to identify people’s capacity was not being considered in line with the principles of The Mental Capacity Act 2005. There was no effective oversight or system in place that ensured people were having the correct levels of staff support. The systems in place had not identified training was out of date and not delivered in line with the provider’s policy.

We saw spot checks were completed in people’s homes, however they had not identified a model of supported living was not always being delivered.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people.

There were systems in place to ensure the provider worked in partnership with other agencies.

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

The systems in place were not effective, had not identified all concerns, and had not driven improvements, which meant learning opportunities were missed.