Kathryn's 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 remained good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 71 (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. The service demonstrated a positive and inclusive culture, underpinned by clear values centred on providing safe, person-centred care. A relative told us, “The staff are kind and caring, [manager] has been invaluable.”

Staff spoke positively about the leadership team and told us they felt supported and able to raise concerns. Comments from staff included, “I think I have learnt so much since I have been here, I have had so much growth and this makes a good life for residents”, “I love being a carer here and my work colleagues are supportive. They are like my family. The residents here are my family” and “I am so proud to work here, I love my job, I am supported and I feel they think I do well.”

The provider recognised and celebrated staff achievements through initiatives such as an ‘Employee of the Month’ scheme. This provided an opportunity to acknowledge good practice, reward staff contributions and demonstrate appreciation for the work undertaken by the team. Staff told us, “I feel appreciated, they have chosen me as employee of the month, they [leaders] say thank you” and “I won employee of the month, I was chosen out of everyone. This boosted me so much, I got celebration chocolates, had a photo, I really appreciated it.”

There was a shared commitment to promoting people's wellbeing, independence and dignity, which was reflected in staff interactions and care practices observed during the assessment.
 

The provider had 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 did so with integrity, openness and honesty.

The service benefited from capable, compassionate and inclusive leadership. Although there had been a recent change in the management team, this transition had been managed effectively by the provider, helping to ensure continuity and stability for people and staff. Comments from staff included, “We worked with [previous manager] for a while, but we are open for changes, and we are excited as a team” and “The best thing here is our management. We try our best to give a quality of care to our residents.”

Staff spoke positively about the support they received from managers and told us leaders were approachable and responsive to concerns. Leaders promoted an open culture where learning and improvement were encouraged, and there was a clear focus on providing person-centred care. This helped to maintain staff morale, support effective teamwork and ensure people continued to receive consistent, high-quality care. One member of staff told us, “The manager listens to us, and we work to make it better.”

The provider promoted a culture where staff felt able to speak up and raise concerns. Staff told us they felt comfortable approaching managers and were confident concerns would be listened to and acted upon. One senior member of staff told us, “I am open to listening to them [staff], if there is anything I say [to staff] you can come to me and I talk to them.”

Regular team meetings, supervision sessions and day-to-day discussions provided opportunities for staff to share feedback, discuss challenges and contribute to service improvements. The management team encouraged open communication and demonstrated a willingness to address issues when they were identified. This helped to create an open and transparent culture where learning was encouraged, and people’s safety and wellbeing remained a key focus. One member of staff told us, “We are lucky, we talk to [manager] and she has had a good reception from us [when the manager started at the service].” The manager told us, “We have displayed the safeguarding number, CQC number, local authority number, displayed around everywhere on posters. [I say to staff] If you need to speak to me, my door is open.”
 

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.

The provider promoted equality, diversity and inclusion within the workforce and valued the different skills, experiences and backgrounds staff brought to the service. The staff team was diverse, and staff told us they felt respected and included. Leaders fostered a culture where people were treated fairly and where differences were recognised and valued.

Agency staff were welcomed as part of the wider team and were included in communication processes, handovers and service delivery, helping to ensure continuity of care for people using the service. One member of staff told us, “We have a good staff team, agency staff always want to come here, they tell me other places they do not feel welcome but here they like to come. Agency staff are always happy here and it doesn’t take them long to know the home.” This inclusive approach supported effective teamwork and contributed to positive outcomes for both people and staff.

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.

We found some aspects of governance and record keeping required improvement. Records did not always demonstrate when people had been offered drinks or when care and support including personal care had been offered and declined. We discussed these issues with the manager, who acknowledged the findings. They told us they were already planning additional training for senior staff on accurate record keeping. Despite these areas for development, governance systems were in place to monitor the quality and safety of the service, and leaders demonstrated a commitment to continuous improvement.

Audit processes were used to identify issues and drive action, and the management team responded positively to feedback, supporting the ongoing sustainability and development of the service.

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.

The service worked effectively with a range of partners and community organisations to support people's health, wellbeing and social inclusion. Positive working relationships were maintained with healthcare professionals, including GPs, community nurses and specialist services, helping to ensure people received coordinated and responsive care. The provider also promoted community involvement by arranging for external activity providers, entertainers and faith-based services to visit the home, giving people opportunities for social engagement and meaningful activities within a familiar environment.

Relatives and other stakeholders were involved where appropriate to help ensure people's needs and preferences were understood and met. These partnerships helped to enhance people's experiences, reduce social isolation and support positive outcomes.

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

The leadership team demonstrated a clear understanding of the service's strengths, challenges and areas requiring further development. Throughout the assessment, leaders were open, reflective and receptive to feedback, recognising where improvements were needed and showing a commitment to driving this forward.

Feedback provided during the assessment was accepted positively, and action was taken promptly where concerns were identified. Leaders spoke knowledgeably about the service and had plans in place to address identified shortfalls, including improvements to care planning, record keeping and staff development. This proactive and transparent approach supported a culture of continuous learning and improvement, helping to promote positive outcomes for people using the service.