Kingswood House

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 is the first assessment for this service. This key question has been rated inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to good governance.

This service scored 29 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. There had been multiple changes in leadership at the service which had had a detrimental impact on people, staff and relatives. The delivery of high quality care was not assured by the leadership, governance or culture in place. This was evidenced in feedback from people using the service, relatives, staff and visiting professionals. Staff said there had been so many changes in the management of the service all of which brought different systems and processes. A staff member told us, “Every manager comes in with their own ideas and want to change and implement new things and the continuity of care breaks down.”

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively. The service had had many changes in leadership over the previous 11 months. The provider had failed to ensure the service had long-term, full-time leadership dedicated solely to the service to bring back stability and trust for people, relatives and staff. Although individuals demonstrated commitment to service improvement, the provider had not resourced sufficient leadership within the service in a timely manner. The provider had failed in its obligations to keep CQC aware of management arrangements at the service.

People did not feel they could speak up and that their voice would be heard. Although the provider had a policy in place and had implemented initiatives such as a speaking up guardians at the service, these had not been effective in supporting all staff to feel confident about their concerns being listened to. Staff told us, “People do not feel they can speak up, because there is a ‘shape up or ship out’ mentality.” and, “Since March, we have not had a stable manager, this could be better.” Staff were offered supervision, however records indicated that this was an area which needed to improve because sessions had not been consistently completed in line with the provider’s own policy. Some records requested from the provider could not be produced and there were inconsistencies in the quality of the supervision offered, depending on who the supervisee was. Some records lacked evidence concerns raised in supervision sessions were used in a meaningful way by the service to drive improvement.

Some issues of concern were identified relating to workforce equality. Policies and processes were in place to help protect the rights of staff under the Equality Act. Recruitments was undertaken by a centralised team who assessed applicants fairly and based on merit. However, not all staff at the service felt supported or listened to in the workplace. Supervision was sporadic and of variable quality.

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. The service was in organisational safeguarding with commissioning authorities and inspectors found 3 breaches of regulation at this inspection. There had been changes in managers and staff at the service over a long period of time and this had had a detrimental effect on the quality of care delivered. Audits and governance at the service had failed to address ongoing concerns in relation to poor record keeping, a lack of incident reduction, insufficient staff competence, ensuring the environment was suitable for the people supported, care planning and people’s needs assessments. Records did not show learning from incidents was taking place. Although leaders based at the service demonstrated a commitment to service improvement the provider had failed to ensure there were sufficient resources in place to bring about the changes required promptly.

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement. The service was in organisational safeguarding with commissioning authorities. Although the service had engaged with professionals, the response to concerns had been unsatisfactorily slow. A professional told us, “[Professionals at a concerns meeting] were very concerned that it had taken months and several meetings before higher management agreed to attend and support the service.” Communication was an issue at the service and this impacted on information sharing. A professional told us, “There have been differences in information when there have been changes in management which has caused confusion in care planning.” Information passed to the service was not effectively shared between staff teams. For example, where specialist training was delivered to staff to support the safe care of a person, the service failed to take the necessary steps proactively to ensure this knowledge remained in the service when the majority of staff who had received this training were no longer in place. The provider did take steps to rectify this when requested to do so by inspectors.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research. There was little evidence of the service using information from records or feedback from people to address concerns within the service. Records relating to restrictive practices such as restraint were of poor quality and lacked sufficient detail to allow the service to learn from incidents. Staff at the service were not following the provider’s own policy of completing formal post-incident learning reviews. Although these issues were known to the service, steps to address these issues had not been effective at the time of the inspection.