Archived: Kingswood Manor

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 remained the same. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. The service was in breach of the legal regulation good governance

This service scored 54 (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.

During our visit, the culture of the service was open, warm and friendly. The people and relatives we spoke with, confirmed this. They were complimentary about the registered manager and the staff team and told us they were always treated with dignity and respect.

Staff members spoken with were positive about working in the home and told us the registered manager was friendly and approachable. There were processes in place to promote a positive culture, including staff supervisions, staff meetings and service user/relative meetings.

Leaders were inclusive and understood the context in which they delivered care. They did not always however have the skills, knowledge, experience and credibility to lead effectively,

There continued to be a clear management structure in place to support the running of the service. This included the registered manager, deputy manager, regional support manager and regional manager. Staff felt supported to do their job role.

However, there were still gaps in the skills and knowledge of both the registered manager and regional manager with regards to assessment, care planning, medicines management, safeguarding and governance. This impacted on the effective leadership of the service. As a result, significant shortfalls in the quality and safety of the service were found again at this assessment.

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

Whistleblowing and safeguarding were in place to support staff to speak up. Staff told us they felt confident raising any concerns and felt their voice would be heard. Staff meetings took place and records showed staff were supported to share their views and suggestions. There was a complaints policy in place for people to use if they wished to complain about the service. No one we spoke with had any complaints.

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.

The provider had policies in place to support a diverse, fair and inclusive culture, which underpinned staff recruitment, training, working life and staff well-being. Staff felt the management team were fair and approachable and willing to listen to any concerns they have had. Staff felt supported in their job role and felt they were treated equally.

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, or share this securely with others when appropriate.

The management of the service was not effective. The management team did not have the skills or experience to drive up improvements at the service. Clinical oversight had not been adequately maintained and the audits in place to check the quality of care provided were not effective.

At the last 2 assessments, the governance systems in place to ensure people receive safe, good quality care were not robust. At this assessment, systems remained the same. The provider failed to improve the effectiveness of the systems designed to mitigate risks and keep people safe. The serious concerns identified at the last 2 assessments remained. This included concerns with safe care and treatment, medicines, the environment, the management of the service and a failure to ensure safeguarding events were appropriately recognised and reported to CQC. The provider was given ample opportunity to make improvements in these areas following the last 2 assessments yet has consistently failed to do so.

The provider understood it was their duty to collaborate and work in partnership, so services worked seamlessly for people. However, they did not always share information and learning with partners or collaborate for improvement.

The service worked in partnership with a range of health and social care professionals, including the Local Authority. Referral processes were in place to help people access the additional support they needed, and records showed people received this support. Care records however were not always clear or accurate which impacted on the reliability of the information shared with partners to support seamless pathways of care for people. Information about people’s needs and care was also shared with partners at multi-disciplinary meetings, but professional guidance given in respect of people’s clinical care was not always followed.

Statutory notifications to CQC in respect of safeguarding incidents had not always been reported appropriately. This meant CQC was unaware of these incidents and therefore unable to determine if appropriate action and learning had been undertaken.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

This is the third assessment of the service were the same shortfalls in safe care and treatment and governance have been found. This included shortfalls in assessment and care planning, the management of medicines, clinical care, the environment and the audits and checks in place to ensure fundamental standards of care are achieved. This did not show the provider was committed to or focused on continuous learning or driving up improvements across the service.

The environment in which people lived was not dementia friendly, people’s dementia care in general and people’s communication needs were not adequately supported. This was noted at the last two assessments, but no effective action had been taken. This meant the equality of experience, outcome and quality of life for some people continued to be affected. This did not demonstrate a learning culture.

Nursing staff did not deliver clinical care in accordance with best practice guidance to actively ensure safe and effective treatment outcomes. This was noted at the last 2 assessments but remained a significant concern at this assessment due to the continued risk of avoidable harm. This did not demonstrate nursing staff, or the management team actively contributed to safe, effective practice and research.