KYN Bickley

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.This was the first assessment since the service was registered with CQC. 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 registered manager told us they were passionate about improving people’s experiences of living at the service and had a clear understanding of areas of the service which required improvements. This included personalising and ensuring a holistic approach to people’s care plans and improving staff development and career the opportunities for staff.

Staff described told us the culture at the service was positive and the registered manager shared their vision with the staff team.

Observations showed that staff respected the service as people’s home and people chose how they wanted to spend their time. Staff told us they felt supported and listened to by the management team. They understood the values of the service and told us they worked well as a team. A staff member told us, “I have been here when the service was first opened, I know people well. staff can come to me, and I will share my knowledge and experience.”

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.

The managers and staff knew people they supported well and were clear on their role and responsibilities and the systems and processes in place. People and their families interacted positively with the managers and found them approachable. Staff and relatives gave us positive feedback regarding the managers at the service.

People, their relatives and staff were complimentary of the manager and reflected on the increased support and improvements in service delivery which had taken place since they took in the role.

A family member told us the “Registered manager is changing a lot of things, they’ve had a massive change in staff since they took over.” Another family member said. “The registered manager is a lot more proactive to do things, [they] tend to be someone who listens.”

A staff member told us, “I feel valued and supported by the manager.” Another told us, “My manager is flexible and supportive They have helped my wellbeing.”

Another staff member said the manager is supportive of our career developments and gave an example of the manager’s nomination of a staff for an award, which the staff member had won.

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

Staff felt they could speak up and named the managers and seniors they would go to, if needed. Staff did not raise any concerns around speaking up to protect people. We were told by people and their families they could speak up easily and would be heard. One person said, “The communication is actually really good I can get hold of the staff, but I can also get hold or meet the owner.”

The registered manager told us they operated an open-door policy, and they always welcomed staff and visitors to speak to them and raise their concerns at any time.

There were opportunities in place for staff to speak up in the form of staff supervision sessions and managers being visibly present in the home.

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.

There was a diverse workforce at the service. We saw staff were included in discussions surrounding the support provided at the service. A staff member told us, “I feel supported by my manager, and I feel listened to.” The provider supported staff equality and staff told us they were encouraged to be involved in the service and discussions, such as updating people’s care records. The provider’s recruitment was equitable and fair.

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.

We found people’s care records did not always identify the discrepancies we found during our visits in that people’s care records including their related care plans and risk assessments. The provider did not monitor conditions Deprivation of Liberty Safeguarding (DoLS) and ensured these were met and therefore it was not always clear what support people needed or were indeed current.

The provider monitored trends to ensure the service was meeting the requirements and needs of people being supported and where actions were needed, these had been followed up. A wide range of audits took place, and the provider kept records which identified how the service could be improved and what actions were to be taken. These included audits of safe environment, care plans and risk assessments, medicine administration records and staff training.

A number of other audits were comprehensive and used effectively to identify concerns and make improvements for example Health and Safety, and environmental checks were completed, and external contractors were sought for specialist service.

Organisational policies and procedures were clear and up to date.

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.

Managers had good working relationships with partners including community health and social care professionals.

The service worked alongside a variety of external partners to ensure people’s needs were met. External partners told us that there were effective working partnerships, information sharing and collaborations to ensure people had a good quality of life.

Some professionals working in partnership with the service gave feedback commending them on the improvements in care provided. One healthcare professional commented on the ‘very good working relationship’ they had with the team.

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. They actively contributed to safe, effective practice and research.

The service provider recognised further staff training was needed to improve the quality of their care records and documents which included care and risk assessment plans.

The provider focused on continuous learning, innovation and improvement. The management team had a service improvement plan in place based on the findings from internal and external audits and monitoring of the service. Actions were recorded where required and monitored to help ensure that areas of improvement required were implemented to enhance the quality of the service provided to people.

Staff told us they were encouraged to be involved in discussions on how to improve the service for people. A staff member told us, “I do feel comfortable raising suggestions.”