Kairos Community Trust

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

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 changed to requires improvement.

This meant the service did not always have effective oversight and governance processes that were fully embedded.

Although the service had governance processes and procedures in place, these did not always operate effectively, and it was not always clear that managers had appropriate oversight and monitoring of these processes. We identified gaps, such as the lack of a fire risk assessment, gaps in documentation relating to staff supervision, appraisal, fire risk assessment.

However, staff, clients and commissioners gave overwhelmingly positive feedback about the leadership at the service.

The service was in breach of the regulation for safe care and treatment and good governance.

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

The service 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 knew and understood the service's vision and values and how they applied to their work. This had been successfully communicated to the frontline staff in this service by the provider.

The service had a strong ethos of creating a community environment that nurtured trust, responsibility and respect. All clients we spoke with told us the service was ‘like a family’.

Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing. Staff discussed any changes to the service at weekly team meetings.

The service 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.

Leaders were visible in the service and approachable for clients and staff.

The manager and deputy manager worked at the premises each day. Staff and clients spoke positively about the managers and whole staff team.

The manager had a good understanding of the service. The director of Kairos Community Trust visited the service weekly. They also held a meeting with clients every three months to hear about their experience of the service.

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

Managers promoted an open and honest culture.

Clients had opportunities to give feedback on the service they received. For example, through daily morning meetings, one-to-ones with staff and using feedback questionnaires.

Staff felt that they could raise concerns about disrespectful, discriminatory or abusive behaviour or attitudes towards clients and staff with the manager.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

The service had an equality policy in place, staff received Equality Diversity and Human Rights training.

The staff team included people who had lived experience of substance misuse.

The staff were supported with their individual needs. Staff told us the managers supported flexible working arrangements and had regular discussions to understand their individual needs and how they could support them.

The service 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.

Although the service had governance processes and procedures in place, these did not always operate effectively, and it was not always clear that managers had appropriate oversight and monitoring of these processes. We identified gaps in various documentation that we reviewed

Governance processes were not always working effectively to identify areas that needed improvement. The provider and managers did not have clear oversight and monitoring of the risks we identified during this inspection, for example the lack of a formal fire risk assessment, maintaining records of staff supervision, lack of appraisals, and the overall maintenance of records required for the running of the service.

Staff maintained a risk register that recorded specific risks posed by individual clients. Specific operational risks to the service were not recorded on the register.

The service had plans about how to respond to emergencies and disruptions to business continuity.

The service used systems to collect data. Staff kept basic information of length of stay, the number of clients on the waiting list, numbers of referrals that were not accepted and the number of clients who successfully completed the programme.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The service worked in partnership with other health, voluntary and social care organisations to achieve better outcomes for people using the service. There was a good working relationship with commissioners and social care teams.

Feedback from both commissioners we spoke with was overwhelmingly positive, they spoke about effective communication, collaboration, person centred care and managing client risk.

The service 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 contribute to safe, effective practice and research.

There was a learning culture. Managers shared learning at team meetings. Client feedback was discussed so that any improvements to care and treatment could be made.

Two clients told us that the service had supported them to apply for volunteer opportunities with the Amy Winehouse Foundation a charity which provides support for young people with drug or alcohol problems.