All Care (GB) Limited - Lion Oak Court

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 leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. This is the first assessment for this service. This key question has been rated good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 68 (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 a shared vision, strategy and culture. The leadership team had made significant efforts to promote a positive culture the visible and engaged presence in the day to day running of the service. The registered manager had a clear vision for the service, wishing to create a positive, community-based ethos. The provider had a set of visions and values, which the registered manager reflected upon with staff during team meetings and supervisions. They told us this helped ensure there was a shared set of visions and values across the staff team.

The provider had inclusive leaders who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. The registered manager was suitably experienced and qualified in their role. They understood their regulatory responsibilities and were invested in continually working on their own professional development. Senior staff had a good knowledge about their role and had obtained relevant qualifications. The registered manager was receptive to feedback during the inspection. They had begun to address the issues we raised during the inspection process. This reflected an open and responsive approach to improving the quality of care.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us they felt comfortable raising issues or concerns to the management team. They told us the registered manager had an ‘open door’ policy and always encouraged them to air their views and feelings.

The provider listened to concerns around safety and had taken steps to identify lessons learnt from incidents that had occurred. However, actions taken in response to incidents were not always fully embedded and more work was needed to ensure all staff understood how to apply learning. For example, the provider had worked collaboratively with stakeholders to improve fire safety at the service. However, some staff told us they were unsure about fire evacuation procedures for different scenarios that may arise. They said they would benefit from additional learning opportunities to reaffirm their knowledge. The registered manager told us they would organise learning sessions, to help ensure staff were secure in their understanding.

Audits were in place to monitor risk and quality in the service. The provider also had internal quality teams and had commissioned an external company to complete a quality audit, which was in line with CQC’s assessment framework. Whilst these measures had identified some improvements, their findings were not fully reflective of the issues we identified at this inspection. The registered manager acknowledged the shortfalls we found in relation to guidance and information relating to people’s care plans, risk assessments, medicines and daily records. They had audited people’s care plans and were in the process of systematically reviewing and updating them to ensure they were always comprehensive and clear. They told us they had organised for additional administration time for senior staff at the end of each working day. Senior staff would use this time to review people’s care records and record all updates and actions, including recommendations from healthcare professionals and changes to people’s prescribed medicines. The provider’s electronic care planning system enabled key messages and updates to people’s care plans to be effectively communicated staff upon their next care visit to people. This would help to ensure key changes to people’s care would be promptly documented and be made available for staff to follow. At the time of our inspection, these improvements were in progress. We found that recently reviewed care plans included more comprehensive information around how risks related to skin integrity, falls and time critical medicines would be managed and reduced. The provider required additional time to embed improvements around communicating information with staff and further work was required to complete all care plan reviews.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. The registered manager had built links with different stakeholders locally to create a connection between the service and the local community. This included links with local charities and schools to provide meaningful activity and engagement for people. This helped to ensure people could continue to be part of their local community if they wished.

The provider did not always effectively embed continuous learning, innovation and improvement across the organisation. The provider had identified areas for improvement. However, progress was not always quickly implemented or embedded. The registered manager had an overall service improvement plan, which detailed areas for improvement and development. These areas included, improving the accuracy of care plans, detail of risk assessments and improving fire safety. The action plan was reflective of some of the issues CQC identified at this assessment, with some actions still ongoing at the time of our inspection. After receiving feedback during this inspection, the registered manager added additional actions to the improvement plan as required.