Kismet 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 inspection we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant the governance was inconsistent. Systems and processes for identifying learning from incidents and complaints, and ensuring these are always recorded, were not always effective. The provider was previously in breach of the legal regulation in relation to good governance. At this assessment we did not identify sufficient improvement, and the provider remained in breach of this regulation.

This service scored 62 (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. Staff and leaders we met were committed to the service and to the people they supported. Morale within the team was good, and staff spoke positively of managers and their roles within the service. The provider respected people’s human rights and valued diversity within the organisation. A staff member said, “The provider likes to run the home as if her family lived here.” Another commented, “I feel like staff have a good relationship with residents.” Feedback from professionals was also positive. A professional said, “I feel overall the service is managed very well. Their service is person centred and actively works with the individual to achieve their goals.”

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. People and their relatives told us they felt able to raise any concerns with the provider. During the site visits, leaders were visible, engaged, and actively contributed to the assessment process. The service had an established registered manager in post, and staff spoke positively of the support they received from the leadership team. The provider was open and transparent about challenges the company had experienced, as well as its plans for development. While governance systems were not always effective, the management team was responsive to feedback and took action to address shortfalls identified. Professionals who worked with the service told us the leadership team was responsive and collaborative in their approach. A professional said, “Managers are easily contactable, and they are approachable. They are happy to discuss matters and work together in partnership to find solutions.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us they felt supported and able to raise concerns with the management team. One staff member said, “I would have no hesitation in going to the registered manager or provider.” Staff described the management team as approachable and told us they maintained a visible presence within the service, which supported open communication. There were processes for staff to speak up, including team meetings and supervision sessions. The provider had procedures to support staff in raising concerns and contacting external agencies when necessary.

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 management team told us how they supported the diverse needs of staff, including those with protected characteristics. This included offering flexible working arrangements for staff with health conditions and respecting individuals’ religious beliefs. Staff had received training in equality and diversity and told us the management team was approachable. We were given examples of periods when staff had faced personal difficulty, during which management had been supportive. One staff member said, “They’ve always listened to me.”

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. Audits completed at service level did not identify or address shortfalls found during this assessment. For example, audits related to medicines and environmental checks were not effective at identifying and addressing the issues we found. Processes for auditing incident records, staff induction, supervision and training were not sufficiently robust to highlight areas for improvement and were ineffective in identifying the shortfalls we observed. The provider maintained a regular presence at the service, covering in the registered manager’s absence when required. However, they were not conducting formal provider audits, which may have identified the issues we found. Policies and procedures were in place; however, not all had been updated to reflect current working practices within the service. For example, those relating to incidents and complaints had not been updated to account for electronic record keeping. This meant staff lacked clear guidance to follow, for example when recording incidents. Governance processes had led to some improvements since the last inspection, for example in relation to environmental risks and infection prevention and control. While service level audits were not always effective, improvements had been made to ensure they were carried out regularly, with some new systems and processes introduced since the last inspection. The management team responded positively during the assessment, providing evidence of actions taken to address the shortfalls identified.

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 registered manager told us how they worked in partnership with professionals such as the GP, social workers, and the community mental health team to meet people’s individual needs. The management team told us they participated in provider forums to exchange ideas and share best practice related to service delivery. Professionals who worked with the service told us there was good communication between the provider and external agencies. A professional said, “They work with professionals and family members to provide the best possible outcomes for the residents.”

The provider had not always focused on continuous learning, innovation and improvement in the service. At the last inspection, we identified risks relating to the service environment, medicines, and infection prevention and control, which were not always effectively assessed or mitigated. At this assessment improvements had been made, however, we also identified additional shortfalls in relation to incident recording and staffing. Learning following incidents and complaints was not always well documented. The provider had a service improvement plan, and during the assessment, it was updated to reflect actions identified during the assessment. Processes were in place to involve and gather feedback from people, including a monthly survey and regular meetings with allocated key workers. Relatives and staff told us communication with the management team was positive, however there had been no recent formal process to capture feedback. Despite this, staff reported having opportunities to share feedback and ideas with the management team, both informally and through meetings. During the assessment, the provider began a formal survey requesting feedback from relatives. The management team told us they participated in provider forums and maintained a positive working relationship with the local authority to support service improvement.