Ladyfield House

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. 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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. Some members of the management team were not aware of some systems and processes and were therefore not always able to offer guidance and direction to staff.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively. The management team did not always effectively share information between each other.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff were confident to speak up and had access to the whistle blowing policy. Staff felt the management team would take action to address concerns. Staff team meetings took place and discussions were documented.

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. Staff had access to policies and procedures to support them ensuring their preferences were considered and actioned where appropriate.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Audits in place to monitor the quality of the service needed further development and embedding in to practice to ensure they identified current issues in the home. There was a lack of action plans in place to address current issues.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborate for improvement. The service worked with partners to ensure people received better outcomes. People had access to local clinical services to help ensure they had the right care to meet their needs. We saw people's care plans included referrals to healthcare professionals as and when required.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research. Since our last inspection the service had declined form a rating of good to requires improvement. There had been some missed opportunities to learn and improve the service. This led to concerns being highlighted by external professionals. However, the management team could demonstrate actions they had taken to address these concerns. New systems required embedding in to practice to ensure their efficacy.