Kemple View

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• 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 Outstanding. At this assessment, the rating has changed to Good.

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

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.

We have a shared vision, strategy and culture that is based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding and meeting the needs of people and our communities.

• Staff knew and understood the provider’s vision and values and how they were applied in the work of their team.
• The provider’s senior leadership team had successfully communicated the provider’s vision and values to the frontline staff in this service.
• Staff told us they had the opportunity to contribute to discussions about the strategy for their service and could discuss this when senior leaders visited the service. Staff had been proactively getting involved and organising the wards activities.

We have inclusive leaders at all levels who understand the context in which we deliver care, treatment and support and embody the culture and values of their workforce and organisation. They have the skills, knowledge, experience and credibility to lead effectively and do so with integrity, openness and honesty.

• Leaders had the skills, knowledge, and experience to perform their roles.
• Leaders had a good understanding of the services they managed. They could explain clearly how the teams were working to provide high quality care.
• Leaders were visible in the service and approachable for patients and staff. Staff explained senior leaders visited the service and were able to discuss new ideas they may have for the service. For example, one staff member designed the activity sessions for the whole week for one of the wards.
• Leadership development opportunities were available, including opportunities for staff.Staff told us they had the opportunity to develop within their role with one completing a leadership course.
• Leaders had the skills, knowledge, and experience to perform their roles.

We create a positive culture where people feel that they can speak up and that their voice will be heard.

• Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. The service had a complaints book, and patients could access advocacy. We observed a patient safety meeting where a patient representative from Oakwood ward was present. There was a feedback box in the family room which provided an opportunity for families and carers to share feedback. Carers were also given information about raising concerns in the family and friends’ information booklet. However, patients told us they could not always provide anonymised feedback.
• Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements.
• Patients and staff could meet with members of the provider’s senior leadership team.

We value diversity in our workforce. We work towards an inclusive and fair culture by improving equality and equity for people who work for us.

• The provider had a number of networks that staff could be members of, including LGBTQ+, Black and Minority Ethnic and parents’ networks and there were champions as part of those networks across the hospital.
• Staff were able to apply to work flexibly, for example staff had flexible working agreements to account for personal circumstances such as caring responsibilities and health issues.
• Managers put reasonable adjustments in place for staff members to help them carry out their role.
• The provider undertook equality monitoring of staff within the service to ensure it was diverse in its make-up and representative of the patient group.

We did not always have clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support. We act on the best information about risk, performance, and outcomes, and we share this securely with others when appropriate.

• Management of risk across the service was not robust. There were several policies that were insufficient to ensure staff and patient safety. For example, the service’s ‘transfer patient to another ward’ policy lacked detail including the type of vehicle that should be used, or the minimum number of staff members required for safe transportation. There was also no guidance for staff to follow to ensure adequate risk assessments were carried out for each patient prior to transport taking place in this manner. Following the on-site inspection, Kemple View acknowledged the need for greater policy detail and the creation of a transfer checklist.
• Additionally, there was an incident on Hawthorn ward in December 2024 which resulted in a patient being mechanically restrained using handcuffs. The mechanical restraint had not been individually risk assessed for the patient and there was no policy in place in relation to the use of handcuffs on the rehabilitation wards.
• The service’s most recent fire risk assessment detailed action required to ensure safety with regards multiple fire doors. These concerns were not detailed on the service’s fire risk assessment register, although when we raised this, we were informed this was due to a technical issue and that this was documented on the site improvement plan. These concerns were documented within the health and safety committee, although it was not clear who was responsible for undertaking the work, what action was being, or going to be, taken, or timescales for any works to be completed. There was an outstanding action to ensure doors do not have excessive gaps between the door and the frames from October 2024.
• The heating in the building had been on the risk register since 2023.
• Staff did not always have access to the equipment and information technology needed to do their work. The information technology infrastructure, including the internet did not always work well. Staff told us there was not always enough computers available and that that the internet connection was unreliable. IT system failure was on the service risk register and an IT business continuity plan and disaster recovery plan were in place. Information governance systems included confidentiality of patient records.
• Managers monitored performance and addressed issues with individual staff members when these were identified.
• The service used systems to collect data from wards and directorates that were not over-burdensome for frontline staff.
• Team managers had access to information to support them with their management role. This included information on the performance of the service, staffing, and patient care.
• There was a clear framework of what must be discussed at a ward, team, or directorate level in team meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed. Staff had monthly team meetings and managers had weekly operational meetings and monthly ward managers meetings. These linked into daily patient safety meetings, monthly clinical governance and the clinical development group which occurred every 6-8 weeks. Information was then shared at regional and board level through monthly regional governance meetings and board meetings. Patient and staff feedback were represented within meetings.
• Staff maintained and had access to the service risk register at ward or directorate level. Staff at ward level could escalate concerns when required. The risk register reflected concerns relevant to the service and was updated regularly. However, it did not detail the action required to ensure safety with regard to multiple fire doors, which was highlighted in the service's last fire risk assessment.

We understand our duty to collaborate and work in partnership, so our services work seamlessly for people. We share information and learning with partners and collaborate for improvement.

• Directorate leaders engaged with external stakeholders, such as commissioners,’ social services, and external healthcare providers. Commissioners told us that staff were open and transparent and responsive to feedback and any concerns raised and that managers engaged openly in meetings when further information or assurance was required.
• Patients and staff could meet with members of the provider’s senior leadership team and commissioners to give feedback.

We focus on continuous learning, innovation and improvement across our organisation and the local system. We encourage creative ways of delivering equality of experience, outcome and quality of life for people. We actively contribute to safe, effective practice and research.

• Staff were given the time and support to consider opportunities for improvements and innovation and this led to changes. Innovations were taking place in the service. For example, managers recognised that leave planning was not being used effectively across the service. A project was put in place to improve leave planning and to use itinerary planning more effectively. One staff member within Hawthorn ward was actively involved in increasing activities scheduled for the ward. One staff member within Hawthorn ward was now completing a leadership qualification.
• Staff used quality improvement methodologies and knew how to apply them.
• Staff participated in national audits relevant to the service and learned from them.
• Wards participated in accreditation schemes relevant to the service and learned from them.