Lilleybrook Care Home

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 good. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Whilst leaders had the skills, knowledge, experience and credibility to lead effectively, oversight and governance had not always been effective. 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 at the service.

This service scored 61 (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 clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. However, the concerns we identified in relation to governance meant that this was not always peoples experience.

Whilst we received positive feedback from staff, people and relatives about the culture of the organisation, we also heard that some relatives did not believe their loved ones received the care and attention they needed in a timely manner.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We shared feedback with the registered manager about our findings during observations on day one of the assessment. This feedback raised concerns about people’s mealtime experience and the level of oversight and timely interventions from staff. The registered manager told us that staff had acted outside of their usual practice as they were being observed. Despite this, the registered manager was responsive and acted promptly to speak with staff and discuss their practice and the impact on people’s experience. We completed an observation on day two of the inspection and noted that people’s experience was much more positive.

Staff confirmed good communication within the team and said they were being kept informed about any changes. The registered manager told us they felt supported by the provider. We saw examples of this support throughout the entirety of the assessment process.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support. Whilst leaders had the skills, knowledge, experience and credibility to lead effectively, oversight and governance had not always been effective. During feedback the registered manager and provider were responsive to the concerns raised in relation to governance.

We mostly received positive feedback from people, relatives and professionals in relation to the management of the home. One relative said, “[The registered manager] knows what the staff have to do. [The registered manager] is approachable, listens and will get things sorted.”

The registered manager demonstrated a commitment to the service, knew the people in their care well and was visible within the home. The registered manager and deputy manager completed a daily review of people’s electronic care records, and worked alongside staff to oversee their practice and how the well-being of people was supported. A person told us, “The manger is on the floor all the time. [They say they] prefer to be on the floor than the office.” More time was needed to ensure that the day-to-day oversight was reflected in the record and overall governance of the home.

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

The service had an up-to-date compliments, complaints and suggestions policy and procedure. Staff demonstrated an understanding of whistleblowing and could explain what they would do if they needed to escalate concerns about poor practice. One staff member said, “The registered manager has always supported me. We have worked together for years and I can go with any concern.” Another staff member said, “There is definitely an open culture here so If I had a concern I would feel safe to [raise it]. I would 100% feel that I would be listened to.”
 

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

Leaders took action to address any disparities in staff experience and worked to ensure equitable opportunities for development. Staff spoke positively and told us they felt supported by the management team. One member of staff said, “I am happy working here. Management are brilliant and really supportive.”

Training records showed staff received equality and diversity training, which supported awareness of inclusive working practices. A senior member of staff told us, “We have a lot of different cultures and that has been fantastic. We all work as a big team and recognise and respect everyone’s culture.”

Whilst the provider had responsibilities, roles, systems of accountability and governance, these were not always operating effectively, and we did not consistently see a clear record to support practice.

There was a governance structure in place to support the provider and management team to undertake their roles. However, the governance systems we saw at the time of inspection had not been consistently operated to effectively monitor the service and identify the shortfalls we saw in relation to care planning and medicines.

There was an active service improvement plan in place which had been routinely reviewed. However, completion dates indicate that compliance deadlines have not always been met. In some instances, these delays extend several months beyond the agreed compliance date. Whilst some concerns in relation to missing care plan information or discrepancies had been noted in the service improvement plan for specific people, these had not covered the breadth and depth of concerns that we identified on inspection. In contrast, we saw some examples of concerns in the service improvement plan being followed up promptly, with actions and updates recorded.

Care plan and medicine audits had taken place, but they had not always identified or taken timely action to remedy the inconsistencies in records or concerns that we found on assessment. For example, one person had been prescribed medicine which their care record indicated they were allergic to. We discussed this with the registered manager who told us that, despite the record, the person was sensitive to this medication and not allergic. We saw this had been fully discussed and agreed with health professionals before prescribing. Despite this, there was not a clear record to demonstrate the rationale and agreement for this decision from the care home’s perspective. We shared this with the registered manager who took immediate action to resolve.

The registered manager was completing a daily review of people’s electronic care records and was acting when concerns were identified, for example when people had low fluid intake. Whilst this was helping to mitigate the risk to people, more time was needed to develop a consistent governance structure which fully identified and resolved, in a timely manner, the shortfalls we saw in relation to care planning and medicines.

We received mixed feedback from professionals about whether the provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. Some professionals told us the service did not always share information and learning with partners or collaborate for improvement, whilst others shared positive feedback about effective partnership working.

Leaders and staff cooperated with external agencies during safeguarding processes and followed agreed procedures. This demonstrated the service understood its responsibilities when working with partners to protect people.

People also benefited from links with the local community and external organisations. For example, staff worked with specialist providers to deliver activities such as therapy animal visits, which supported people’s social interaction, stimulation and emotional wellbeing. Staff also maintained links with a dementia choir in the community and received visits from a local charity reaching people with dementia through music and song. This provided meaningful opportunities for interaction and helped people remain connected to their community.

Whilst the provider focused on continuous learning, innovation and improvement across the organisation and local system, the shortfalls we identified in governance meant that we were not always assured they were encouraging creative ways of delivering quality of life for people.

There was a service improvement in place, governance meetings and processes and procedures to support a learning culture within the organisation. However, there was not always a clear record to show that these were being used effectively to identify all areas for improvement or drive consistent progress. For example, the service improvement plan had detailed that a person’s falls risk assessment needed to be reviewed. This had been completed, but the risk assessment still did not include important information about blood thinning medication and the increased risks this poses if the person were to fall.

Completed audits and checks did not always include meaningful analysis, which restricted the insight they provided into the quality of care or the actions required. For example, medicines audits and care plan reviews had been completed, but had not identified the inconsistencies and missing information which we identified on assessment.