Kingsthorpe Grange

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 inadequate. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

The provider was previously in breach of the legal regulation in relation to good governance. Significant improvements had been made, and the provider was no longer in breach of this regulation.

This service scored 75 (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.

There was a positive culture at the service. Staff told us, “The culture here is caring and supportive. In my opinion, everyone does their best to support the residents. Staff work together as a team to provide high-quality, person-centred care”.

The registered manager told us they felt the service was family orientated and had a transparent environment which they personally enjoyed working in. They told us they were proud of the improvements that had been made, they said, “The staff are amazing, and we deliver. We have worked so hard to get here.”

The provider had ensured that all staff were aware of the new leadership structure and lines of accountability, which had been reinforced through revised communication channels, including newsletters, and regular visits from senior leaders to strengthen staff engagement and accessibility.

Regular team meetings, handovers, emails and supervision helped staff to feel involved in the service and kept updated about any risks or challenges. The provider monitored and reviewed progress with improvements and plans at the service.

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, their relatives and staff were confident about the leadership of the home. Staff felt the management team were approachable, fair and supportive.

People’s relatives felt they had made improvements to the service. A relative told us, “The manager does seem to be trying to turn things around.”

The registered manager told us they received regular supervision, had meetings with peers and felt supported by the provider and the wider management team.

The registered manager had a visible presence within the service and were available during our site visit. They had the skills, knowledge, experience and credibility to lead effectively and were open and honest during this assessment. The new nominated individual’s management team were knowledgeable and interested in wider issues such as the recent changes to the Care Quality Commission (CQC) methodology and the implementation of the Single Assessment Framework.

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

Staff overall felt the management team would address any concerns they had. We saw evidence where concerns had been raised, the management team investigated them sensitively, and were acted on and lessons shared. Staff confirmed this and knew how to report concerns about poor standards of care. One staff member told us, “I feel comfortable voicing my concerns and suggestions. Management is open and approachable, and they listen to what staff have to say. I’ve seen that when issues are raised, they are taken seriously and acted on.”

The registered manager told us the service actively supported staff to speak up with any concerns and that they were committed to embedding a transparent and open culture at Kingsthorpe Grange.

Policies included the topics of safeguarding and whistleblowing, and information was displayedaround the service to encourage staff to speak up.

The service has a Freedom to Speak Up Guardian, which was leading externally facilitated listening groups across all of the provider’s services, ensuring staff concerns can be raised safely and confidentially. The registered manager told us, outcomes from these sessions will be shared with leadership and acted upon, with feedback loops in place so staff can see the changes made as a result of their input.

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 understood their role and responsibilities. All staff and managers spoken to identified with a shared commitment to good practice and an open approach to problems and issues.

Staff felt supported in doing their jobs and spoke positively about teamwork, shared values and care for people. A staff member told us, “I feel valued, supported, and respected in my role. Both management and my colleagues are approachable and always willing to help. My contributions are acknowledged, and I feel that my voice is heard”.

Staff described management support for them to achieve a good work-life balance, and care and flexibility when health or family circumstances required it.

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

People, relatives and staff were complimentary about the management team and the other staff working in the home. Staff understood their role and responsibilities. They told us they felt they managed to maintain a quality service because they had good working relationships with residents, cared for them, wanted to keep them safe and provided person centred care.

The provider had systems to monitor and improve standards and safety. Audits of topics such as medicines, falls and infection prevention and control were carried out regularly. There was oversight within the organisation which helped to hold staff to account, keep people safe, protect their rights and ensure quality care was provided. There was evidence that actions had been taken to resolve shortfalls.

Improvements had been made with the governance and oversight of patient safety and culture within the service. Audits and checks had been reviewed. The new nominated individual’s management team told us they were keen to sustain the new robust approach to governance and oversight at Kingsthorpe Grange.

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.

People were encouraged to maintain relationships with those who were important to them, and visitors were welcome in the home.

People and their relatives told us staff worked closely with health professionals, community groups and local churches.

Staff worked closely with external agencies and the local community to ensure people could access the services they needed.

Kingsthorpe Grange had a good level of partnership working with other agencies and professionals. Staff and leaders were open and transparent during this assessment process and engaged fully with the assessment team.

The provider focused on continuous learning, innovation, and improvement across the organisation.

Staff were encouraged to raise concerns and suggestions and told us they felt listened to. Staff surveys and regular team meetings supported ongoing review and development. Managers and the staff team were committed to providing the best outcomes for people. During the inspection leaders acted promptly to address any suggested improvements.

Staff received regular training and updates. The provider ensured lessons had been learnt around the level of people’s needs they were able to support within the service. The provider and registered manager regularly shared information with the staff team to ensure they were aware, and this helped support staff understanding and support.

The provider had an overall service plan and specific action plans which provided evidence of ongoing learning, innovation and improvement. The impact and outcomes of people’s care were measured with people, relatives, staff and other professionals as relevant.