Kensington Hall

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 requires improvement. 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.

This service scored 71 (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. The provider and the management had a clear vision for the service and the culture they wanted to create. This was communicated well to people and staff through staff supervisions, meetings and in service user guides. Staff spoke positively about the culture in the home. A staff member told us, “It’s a lovely place to work. Everyone gets on well with each other."

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.

Managers led by example, they knew people in the home well and directly supported people. For example, we observed the registered manager patiently help someone to get ready to go out, and they went with them for a walk. The senior support worker regularly deputised for the registered manager and was being supported to develop their skills and complete management training.

We received positive feedback from relatives and staff about both the registered manager and the senior support worker. A relative told us, “The manager is wonderful, they listen to me and respond where needed. They also keep me updated on anything I need to know,”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Policies supported staff to speak up, providing routes for anonymous concerns as well as signposting them to external agencies. Staff told us they felt confident to speak up. A staff member told us, “Managers made it clear we can go to them with any issue, no matter what it is.”

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. Recruitment processes, training and policy and procedures were in place to support equality, diversity and inclusion. Staff told us they felt they were treated fairly.

The provider 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. The provider had notified CQC of most reportable events in the home, but we found some occasions where this had not happened. The registered manager gave assurances that this had been an oversight, and they were aware of their responsibilities to notify CQC of significant events. There was no impact on people, the management had taken actions to protect people from harm and had undertaken lessons learnt reviews to reduce the risk of incidents reoccurring. Improvement was needed to ensure appropriate notifications were made to CQC going forward.

Management checked on the quality and safety of the service. Audits had been completed covering key areas such as quality of care, health and safety and medicines. While generally detailed and robust, audits had not identified the shortfalls around notifications to CQC. Where actions had been identified these were included in the home’s actions plans.

Staff and relatives gave positive feedback about management and governance, and the home was supported by the wider organisation.

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 home had a network of partnerships and had built relationships with other services in the local community. A staff member told us, “We have a good relationship with families and professionals.” A visiting professional described how staff had supported their visit, staying with the person to give support and reassurance. The professional told us, “Staff have been really accommodating."

The provider 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. Improvements had been made since the previous assessment. Managers learnt from feedback from other agencies, people, staff and relatives. Learning was shared within the organisation, across other homes and services.