Kingsley

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 changed to Requires Improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to checking people received safe support and continually improving the service.

This service scored 54 (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 did not have a clear shared vision and culture which was based on equity, equality and human rights, diversity and inclusion, and engagement. There was a lack key values and goals for the service. We reviewed a number of documents sent to us by the provider. These were in three different company names. One was the provider’s previous name, one their current name and the third another company owned by the company directors. Staff were unable to explain what the visions and values of the service were. They did not feel there was a culture of collaboration, where they were listened to and communicated with. They told us they had not seen anyone from the provider organisation in several years and felt ‘isolated’.

The registered manager told us the provider sent them ‘slides’ each week which they discussed with staff. However, staff were unable to tell us how this supported them to understand the provider’s vision and how it applied to their roles. The registered manager reminded staff about their roles and responsibilities during staff meetings, including the risk of becoming complacent in their work and reminding them people should always be treated with respect and their privacy should be respected.

Not all leaders understood the context in which the service delivered care and support. The provider sent regular information to the registered manager about how they expected the service to be delivered. However, these did not have the correct provider name on them and did not relate to the support being provided at the service. For example, they referred to ‘community programmes’ which were not in place at the service. Other guidance instructed staff to walk next to people rather than in front or behind them to keep people safe. No consideration had been given to people’s individual preferences and how they would like staff to support them.

The registered manager had not been supported to continue to develop in their role. They completed the same training as staff but had not been supported to complete further training to enable them to support staff development and continues development of the service.

Staff told us they felt supported by the registered manager but not by the provider. They told us the registered manager was approachable and always available to offer support and guidance. Staff were confident tell the registered manager if there was a problem and were assured they would be supported to address it.

The registered manager fostered a positive culture where people and staff felt they could speak up and their voice would be heard. However, the provider had not acted to prevent a closed culture developing. Staff at the service were isolated and had limited contact with the provider or other services. No checks had been completed on some staff to ensure they knew how, and were confident, to raise any concerns they had. There was a risk if the registered manager was absent that concerns would not be shared and acted on to keep people safe and well.

The provider had not put systems in to operation to ensure there were clear lines of communication for staff to raise any concerns they may have about colleagues who were related to a member of the leadership team. There was a risk staff would not be confident to raise concerns with a member of the leadership team about their relative. We would expect systems to raise concerns directly to the provider to be clearly communicated with staff.

The provider demonstrate they valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Action had been taken to ensure staff were treated equally, this included staff who were related to members of the leadership team. Staff did not raise any concerns with us and told us everyone was treated equally by the registered manager. The registered manager explained how they ensure no staff member was given preferential treatment.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Effective systems were not in operation to keep the quality and safety of the service under review. Robust checks had not been completed and shortfalls continued unchallenged. For example, shortfalls in relation to medicines management, risk mitigation, the environment and infection control had not been identified and continue unaddressed placing people at risk of harm. The provider had failed to keep the culture of the service under review to ensure it is always operating in line with the principles of our Right Support, Right Care Right Culture and other best practice guidance.

The provider did not understand their duty to work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement. They were not consistently following the principles of our Right Support, Right Care, Right Culture guidance to ensure people were an active part of their local community. They did not always work with other service provider’s or stakeholders. For example, the registered manager and staff were unaware of other services in the local community which had developed in the past few years, which people may like to use, such clubs and events where people with a learning disability can meet other people, socialise, make new friends and try different activities. Following our assessment the provider told us they had acted on our feedback.

The provider did not focus on continuous learning, innovation and improvement across the organisation. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people.

The lack of oversight at the service and failure to gather the views of people, staff and other stakeholders meant the need for improvement at the service had not been identified. There were no systems in operation to review the service against recognised guidance such as our Right Support, Right Care Right Culture guidance. The service did not have any external relationships that supported improvement and innovation. They did not attend conferences or training offered by the local authority to keep up to date with changes or developments in the care for people with a learning disability. No improvement or development plans were in place at the time of our site visit and these were only put in place once we had identified shortfalls. The registered manager confirmed that some actions had been completed by the timescales set but others had not and continued. The action plan had not driven continuous improvements at the service.