Lillie-Rose Home Care

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. This was the first inspection for this service. This key question has been rated outstanding. This meant service leadership was exceptional and distinctive. Leaders and the service culture they created drove and improved high-quality, person-centred care.

This service scored 89 (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. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an exceptional understanding of the challenges and the needs of people and their communities.

We reviewed multiple pieces of evidence which showed the provider had a clear shared vision and fostered a culture of equality and inclusion across the team. Staff induction included information on the providers values and expectations. The registered manager held a meeting with staff on joining to obtain feedback and use this information to make positive changes at the service through actively listening to and responding to staff.

Throughout the process the leadership team were open and honest and open to feedback from the inspection team. They showed a clear understanding of the needs of people and the local community, and this shared vision, and culture was embedded in ways of working.

All staff were clear about the services values and what that meant. One staff member said, “We approach every client with kindness, compassion, empathy, respect, and integrity, We are committed to have the highest standards for each client. These standards never drop. We deliver excellent service to each client.”

The provider had exceptionally inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience, and credibility to lead effectively. They always did so with integrity, openness, and honesty.

The leadership team, including senior leadership, embodied the services values and role-modelled this to their staff team. Senior leadership were available to all staff and approached their role with commitment to improving care quality and supporting their staff. We saw from training records and discussion with the leadership team that they had relevant experience and skills to lead with credibility.

Staff consistently told the inspection team that leaders were capable and compassionate. One staff member said, “I feel they [leaders] have ampuls of knowledge and understanding. Each individual staff member has told us about their past working history, I feel they have the experience, knowledge and understanding to be in the role they are in. They never hesitate with answers, all answers are extremely thorough when I’ve asked a question.”

We reviewed evidence of discussions with staff regarding training and future development and progression and all staff at every level felt supported in their role. The director told us, “We have invested a lot into training, it’s an investment in staff.” The registered manager said, “We have 9 members of management which the directors have invested in to ensure we have stability.”

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

The provider had an appropriate policy for Whistle-Blowing which staff were aware of and staff felt there was a culture of openness, they could speak up and would be listened to. Staff were given the opportuntity to complete feedback anonymously to further encourage open and honest engagement. One staff member said, “The leaders do encourage me to speak. I have spoken up about a concern and I spoke with management. I had a word with my care coordinator and registered manager and they sorted it.”

The provider had created a set of 3 videos led by one of the directors in addition to mandatory learning to highlight the importance of whistleblowing which staff watched as part of their induction. The director told us, “By making the video personalized from the real directors, we know it gives the team more confidence in coming forward. It covers how issues need to be raised, how they will be managed, how they will be protected, and what will happen around outcomes. It talks about how to report the most senior Managers and Directors in the company should then need to.”

The provider clearly demonstrated they valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them and demonstrated a high level of empathy towards the staff team.

There was an appropriate equality and diversity policy in place and we saw evidence that the provider embraced and celebrated diversity, for example; organising Eid celebrations in the office and sending group messages to the team to celebrate Diwali.

We saw clear evidence that the provider took exceptional care to ensure staff diversity was not only celebrated but that they went out of their way to demonstrate this in practical and supportive ways. For example, during Ramadan the provider adjusted staff rotas, without compromising people’s care, in acknowledgement of the physical and mental challenges fasting can have on people. The provider arranged a buffet as part of team meetings, and we saw communication with staff to ensure any specific dietary requirements were met.

Staff felt the provider valued diversity in their workforce. One staff member told us, “In my situation , the company really valued me as a person, I started as a carer and progressed in my career within the same company . I can clearly say the company didn't bias me based on my culture or ethnicity. They purely saw my hard work , compassion to care ,my qualifications and recognised my talent. Yes, everyone really treats me well and is supportive.”

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver high-quality, sustainable care, treatment, and support. They always acted on the best information about risk, performance, and outcomes, and shared this securely with others when appropriate.

Everyone employed at the service had a clear understanding of their role and responsibilities and we saw people had a job description as well as induction and training appropriate to their role.

The provider had invested in technology that supported their oversight of the service and had robust governance processes in place. We saw examples of how the system supported the leadership team to oversee care delivery and they had analysed data on risk to identify trends and themes and corrective action identified which they added to a “live” service improvement plan.

Issues identified and any action to address these, for example: a person who had experienced a number of falls, we saw evidence that this was shared securely with external professionals, the care plan and risk assessments updated, and staff were aware of changes.

We reviewed a quality report that the provider created, this contained data on safeguarding referrals, medication issues identified and addressed, staff survey feedback and future business plans. This was shared with people, staff and external professionals.

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.

We saw evidence of collaboration with partners which included appropriate information sharing and engaging external partners to support with improvements to people’s care.

The provider clearly understood their duty to work in partnership with others and people’s care plans, daily notes and emails evidenced this. One external partner told us about their experience working with the provider, “Staff have contacted me with any concerns they may have regarding a person that is receiving support from them and share all information with me.”

The provider had a strong, proactive focus on continuous learning, innovation and improvement across the organisation and local system. They encouraged innovative creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The provider had invested in and implemented tailor made electronic systems which the director had built to support them to effectively review outcomes for people and made changes as identified which contributed to the safe and effective running of the service. For example, falls monitoring and implementation of increased care and engagement with an occupational therapist to support with equipment where increased falls were identified. The system had integral management checks built in which promoted the management team to review all elements of people’s care for example, daily notes, incident reports to identify and address any patterns or trends. We noted that the system supported excellent service oversight including remote oversight for the directors which contributed to the service making improvements and learning from issues when things went wrong.

The provider engaged with provider forums and other opportunities for learning and improvement, had a thorough service improvement plan which captured ideas and plans for learning and improvement and had set goals for the service that would drive improvement whilst maintaining the quality of care people received. Any learning was communicated to the wider staff team via meetings and messages. The director told us, “We put everything back in the business which is mine and [director] choice what’s important is quality of service and that requires you to invest.”