New Partnerships Lynray and Peach Cottage

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 Requires Improvement. At this assessment the rating has remained 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.

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 had clear vision and set of values which was based on human rights and inclusion and a range of policies and procedures to guide staff practice. However, relatives told us that the new providers values were not always translated into practice and staff did not work in a consistent way. They told us that the culture had changed from what had been family oriented small company to one owned by a large provider and told us that this had impacted on the quality of care which was not as it was.

The provider said that the changes in provider were not recent and they were focused on supporting people to lead the best lives possible.

Relatives expressed concerns about the lack of ownership of issues and their ability to improve. One told us,” The frustrating thing is, there has been some really good staff leave frustrated. Management just shrugs their shoulders and says, well, there's a high turnover in care work.” Another told us “I feel because staff are just completely autonomous, they do what they like and management are not on top of it, because either they're too bogged down, or they think staff are doing what they should be doing.”

We saw examples of where the provider had taken action when poor practice had been identified and used their disciplinary procedures. The provider told us that they intended to take action to build trust with relatives and were planning to set up monthly meetings with them as well as staff to build on their skills and knowledge.

At the time of our assessment Lynray and Peach Cottage had been without a registered manager for some time. The provider had put interim management arrangements in place, and an area manager was on site during the week. A new manager had recently been appointed from within the staff team and had taken up post just prior to our assessment.

Staff and relatives were positive that a new manager was in post and were hopeful that this appointment would provide some stability. A member of staff told us, “A lot of managers are not hands on, this one is.” However, relatives’ optimism was guarded, as they wanted to see improved outcomes for people. One relative told us, “I think predominantly that the service is always in a mess, always inconsistent, I find that there's not enough management, I find there's not enough stringent oversight, I find there's not enough managing of staff.” Another told us, “Realistically, we're not happy with the way the place is run, as simple as that. It's just they've gone through 4 plus managers since they've been there, some have only lasted about 3 months, if that.”

There were on call arrangements which operated outside of office hours, but we saw these had not worked well when a recent incident had occurred. A staff member told us, “The culture here has always been that you should be able to sort things out yourself.” The provider told us that they were taking steps to strengthen the systems in place and remind staff of the procedures to follow.

Systems were in place to enable people and staff to speak up about poor practice. Posters were in display in an easy read format. Staff told us that the management were approachable and would listen to what they say. A number referred to the new manager ‘working on the floor’ and how they had confidence that they understood the issues at the service.

Relatives told us that they felt able to speak up but did not always feel heard or that things changed as a result. One told us, “They said that they keep promising to put it right but never do.”

The provider valued diversity in their workforce. They worked towards a fair culture, and policies and procedures were in place to support equality and diversity. Staff told us that they felt supported in their roles and no one had been subject to any discrimination.

Governance systems were in place, but the provider led audits had not always identified the concerns that we identified during our assessment or ensured that they were addressed. The provider reacted to events but was not sufficiently proactive.

The provider had not ensured that staff were effectively trained and had the skills they needed to keep people safe. There were incidents between people, but positive behaviour plans were not up to date or clear and therefore did not provide sufficient guidance to staff about how to support people who can become distressed. Feedback systems were not effective and did not demonstrate that they were listening to people and relatives.

The shortfalls we have identified are a breach of Regulation 17 [ Governance}] of the Health and Social Care Act 2008 (Regulated activities) Regulations 2014

The provider understood their duty to collaborate and work in partnership with people relatives and other professionals. We saw some examples of joint working such as the work which was being undertaken with the local authority to make improvements. However, we also had inconsistent feedback about collaboration from relatives and further efforts are needed to ensure that care is provided in a seamless way for people.

The provider told us that they were working on improvement and had an action plan in place with the Local Authority. They acknowledged that there was further work to do to but were optimistic that changes would be implemented by the new manager. They responded to our feedback in a positive way, setting out actions at they intended to take.

We saw that they had made some investment into the service with a new bathroom in one of the properties. The service was not currently involved in any research or innovations.