Liberty House Clinic Limited

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

We rated well led as good. We assessed 3 quality statements. The service had established processes for auditing, and reporting on quality, however the service lacked robust oversight and did not make and sustain effective improvements to certain performance areas.

This service scored 86 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders ensured there was a vision, mission and values which were shared with staff at induction. Staff completed training in equality and diversity. Staff demonstrated a good understanding of equality, diversity and human rights.

There were processes in place to ensure progress of the vision, mission and values was monitored. Performance was monitored in regular compliance meetings, to ensure the service was meeting its strategic goals. Leaders ensured there were ways to engage with and involve staff. The service ran weekly staff meetings which had a standing agenda, where information was fed back to staff and staff had the opportunity to share their views.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We reviewed the service’s risk register which leaders told us was reviewed on a monthly basis and was maintained by the registered manager. There were 81 risks identified with actions or mitigations in place. The registered manager was responsible for all identified risks. Leaders worked with staff to try to improve audit outcomes. For example, audit performance was discussed with staff in team meetings. Team meetings and clinical governance meetings followed a clear structure. The service had a business continuity plan in place in order to plan for adverse events that would affect the running of the service.

Oversight of the service was not robust in all areas. People’s previous medical history was not always known and support staff were required to identify and manage risks with virtual support from medical professionals. Action taken to manage risks was not always effective. For example, there were continued medicines related incidents that took place at the service. There were also incidents of people experiencing seizures, and we were not assured that sufficient processes were in place throughout people’s admissions to reduce risks to people. There were concerns in relation to audit compliance. For example, there was inconsistent compliance with observations and good medicines management. Governance policies and procedures did not always contain relevant information. For example, the safeguarding policies and the client well-being check list policy did not provide service level or accurate guidance for staff to follow. However, processes showed leaders had oversight of incidents and promoted a reporting culture. Regular audits and checks were conducted to review compliance and quality of work. These included daily checks of the electronic system, medicines, records and health and safety audits. Governance policies and procedures were available to staff.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Leaders implemented measures to support staff morale within the service. For example, the service added an additional day of annual leave so that all staff could have their birthdays off work and they introduced a reward scheme of shopping vouchers which were given to nominated staff members. Leaders also attended external conferences and information days to improve and share their service specific knowledge.

Staff used an improvement plan to track progress and determine where improvements were required within the service. The plan identified areas of improvement with clear plans of how those improvements would be made, who would make, them, when they would be made and how they would measure those improvements.