Kingsmead Healthcare

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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

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 is the first inspection for this service since its registration with CQC. This key question has been rated as Good.

This service scored 68 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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.

Leaders told us they had maintained an open-door policy, and staff feedback indicated that leaders were approachable. Staff said that if they had any concerns, they had felt safe to raise them and believed they would be listened to. When patients had been affected by things that went wrong, they had received an apology and had been informed of any resulting actions.

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.

Due to the processes in place, leaders were aware of issues outside their direct line of responsibility. The service had policies and procedures which supported a learning culture. The service offered apologies to people, learned lessons from individual concerns and complaints, and took action to improve the quality of care. Staff had clear roles and responsibilities and had shown flexibility to meet patients' needs.Staff told us that leaders were approachable and had responded to concerns raised. Staff also told us that leaders had modelled the values of the service.

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

Staff we spoke with felt that leaders were approachable, listened, and acted in response to matters raised. They told us they did not fear repercussions for speaking up. Processes had also ensured that when things went wrong, people had received an apology and had been informed of actions taken to prevent recurrence.

However, at the time of the assessment, the provider had not identified an independent Freedom to Speak Up Guardian. We discussed this with the provider, who advised that they would ask a member of their Primary Care Network to undertake the role and would communicate this arrangement to staff.

The service demonstrated a strong commitment to diversity within its workforce. Leaders actively promoted an inclusive and fair culture, and staff told us they worked well together and supported one another. There were clear processes for raising concerns, including opportunities during meetings, supervision, appraisals, and through staff surveys.

All staff had completed equality and diversity training, and the service had policies and procedures in place to promote diversity and equality.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Managers met with staff to complete appraisals and performance reviews.

The provider had established governance processes that were appropriate for their service. Staff could access all required policies and procedures. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff. Staff took patient confidentiality and information security seriously, supported by relevant policies and procedures. However, our clinical record reviews identified some weaknesses in governance oversight, including gaps in follow-up and monitoring, incomplete documentation of prescribing decisions, and coding inaccuracies affecting the recording of clinical reviews. While these issues were not indicative of unsafe care, they reduced the provider's ability to demonstrate effective clinical monitoring, recall processes and medicines optimisation.

The service understood its 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 provider worked with other practices within their primary care network to offer extended access.

In partnership with the primary care network, the service ran a weekly arts and crafts group.

The service focused on continuous learning, innovation, and improvement across the organisation and local system. We observed evidence of shared learning and staff involvement at all levels. Leaders had regularly reviewed the service’s assurance systems. Clinical audits and quality improvement processes had positively impacted the quality of the service.

The provider had a well-established Patient Participation Group which they were actively trying to grow. Feedback had been positive, and we were told the group had felt involved and listened to. They met regularly and had been able to submit ideas.

The leadership team had managed clinical supervision and documented all supervision meetings. All staff were encouraged to put forward and trial new ways of working.