Lyles 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

Assessment findings demonstrated an overall deterioration in the standards of care service provided, with breaches of the regulation 17 identified. Shared Direction and Culture: We found evidence of closed cultures within the service impacting on the standards of care provided. There was a lack of provider level oversight to drive quality and safety within the service. Capable, compassionate and inclusive leaders: The provider and interim manager demonstrated a lack of compassionate leadership through their approach to running the service. Lack of structures within the service resulted in poor arrangement of the day to day running of service. Workforce equality, diversity and inclusion: Staff were not treated fairly or equitably. The provider did not place value on supporting and upskilling the staff team. Governance, management and sustainability: There was a lack of clear responsibilities, roles, systems of accountability and good governance at Lyles House. This resulted in the poor management of risk, performance and outcomes. Learning, improvement and innovation: The provider did not demonstrate or encourage a culture of continuous learning. This resulted in poor equality of experience, outcome and quality of life for people.

This service scored 18 (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, and staff team demonstrated a lack of adherence to their own policies and procedures to ensure people received consistent standards of care. The provider was not completing quality audits to monitor people's lived experiences and care outcomes. Overall, the provider did not instill vision and values within the service and organisational structures to drive improvement and achieve compliance with the regulations.

The provider demonstrated a lack of leadership and investment in their staff team. Staff were unclear of their roles, responsibilities and individual accountability. Staff lacked direction and cohesion as a team, and greater value needed to be placed on strengthening staff understanding and knowledge of their roles through training and competency assessments. Staff were not working collaboratively within their own staff team, but also with the local community and external health and social care professionals. The provider demonstrated a lack of understanding of their own regulatory accountabilities as a registered provider, particularly in the absence of a registered manager. The provider was not investing in their staff team to ensure they felt valued and supported. For example, staff were not receiving regular supervision and appraisals to develop their individual performance.

There was a lack of provider level oversight of accidents, incidents and safeguarding events occurring at the service. This did not ensure required onward reporting was being completed, as detailed in the provider's own policies and procedures, as well as in local safeguarding guidance. The provider shared a copy of a report completed by an independent consultant, in September 2023. Action points listed as an outcome of this report had not been acted upon by the provider 4 months later, to demonstrate implementation of feedback and learning into their development of the service.

The provider and interim manager did not lead their staff team by example. We found there to be closed cultures within the service, impacting on the integrity, openness and honesty of the care provided. The provider demonstrated a lack of recognition of their own regulatory responsibilities, particularly in the absence of a registered manager to oversee the safe running of the service and ensure actions were taken for example in response to accidents and incidents to demonstrate transparency of approach.

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.

Staff demonstrated a lack of autonomy in their roles and were not encouraged or supported to give feedback or share ideas to drive improvement at the service. The provider had not ensured their staff team had the required communication and literacy skills needed to meet the requirements of their roles and responsibilities prior to staff commencing their employment.

The provider's HR processes were not consistently followed to ensure prospective staff had the required skills and attributes needed to meet the requirements of their caring role. We identified new staff to not be given an on-site induction to ensure they were familiar with people's assessed needs and layout of the building. We found this to also be an area of risk where the service used unfamiliar agency staff.

Staff demonstrated a lack of their own responsibilities and accountability, including in areas of care such as supporting people with the management of their medicines. The provider and staff team demonstrated a lack of recognition of the management and oversight of risks in relation to the condition of the care environment, and standards of care and support provided, impacting on people's care outcomes.

There was a lack of provider level oversight of the service and performance of the interim manager. The provider did not take overall responsibility for failings at the service, or demonstrate the ability to identify and address poor performance and culture within their service.

People experienced a lack of joined up care, delayed onward referrals and poor collaborative working with external health and social care professionals. People's poor care outcomes were linked to the evidence of closed cultures within the staff team, and staff not having the required training and competencies to recognise changes in people's support needs and overall health presentation. People's changes in needs, or accidents and incidents experienced within a 24-hour period were not discussed during staff shift handover meetings to ensure all staff and management were aware of changes within the risk profile of the person.

Due to a lack of overall provider level oversight, the service was failing to achieve compliance with the regulations.

The provider did not utilise staff meetings, supervision and appraisals as an opportunity to discuss and share learning or implement changes to staff approach and practice as an outcome of accidents, incidents or complaints. The provider did not act on feedback given on day 1 of our assessment to improve standards of safety within the service by our second assessment visit. The provider was not monitoring individual staff performance and was not ensuring staff received regular competency checks to ensure implementation of their training into their practice.