Kenroyal Nursing Home

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 we found the provider had made sufficient improvement and was no longer in breach of regulation.

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 75 (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 and staff all consistently demonstrated a positive inclusive culture and spoke where people remained at the heart of the service.

The provider, registered manager and staff promoted a culture that was caring, organised, and listened to feedback. The provider and registered manager had made improvements to the oversight and monitoring systems and processes, and these were supported by strategy and underpinned with policies and procedures.

The registered manager and staff understood the provider’s vision and values to providing good quality care. It was evident there was a positive and supportive culture existed within the service. People, relatives, staff, and professionals all consistently spoke positively about the leadership and staff working together for the people in residence. One staff member said, “We have a good culture and teamwork. There is a willingness to help each other and the registered manager will ask us to give ideas, and she always listens.”

Daily meetings with provided the registered manager with an overview of the people’s care and any new risks, and they shared key information with staff. Staff meeting minutes showed all essential areas were discussed and staff were encouraged staff to give feedback and share ideas. We saw staff communicating and working effectively and sharing information to ensure people received timely and appropriate care. Staff were respectful of each other’s roles and worked as a team which helped to ensure that people’s needs were met without delay.

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. Feedback we received from health care professionals and commissioners with responsibility to monitoring the care for the people they had responsibility for, was consistently positive about the registered manager.

The registered manager told us; they always had an “open door policy” and welcomed feedback. They ensured they kept their knowledgeable and skills up to date and they were supported by the provider, to deliver good, effective quality care. They understood their responsibilities and kept up to date with relevant changes and notified CQC as required by law. They ensured information was shared with staff promptly in relation to any changes to processes or legislation, was communicated to staff effectively.

People and relatives also consistently had high praise for the leadership. Their comments included, “Definitely, the manager is amazing and always there when I visit, even at the weekends” and “Staff respect [registered manager] and she is always out and about and knows her residents and she knows me quite well as well.”

Staff felt supported and valued. Staff described the registered manager as ‘kind, caring and supportive’. Staff told us the registered manager was knowledgeable and had good awareness of people and were proactively involved in their care. Staff were happy in their role and working for the provider and told us they were well supported by management. One told us, “The manager is always here for us; offers support and guidance. If we don't understand anything, she will help us to understand and explains things.” Another staff member said, “She's ready to listen to any issues, concerns, and suggestions. She is organised and passionate about making care right for people.”

The provider fostered a positive culture where people felt they could speak up, and their voice would be heard. There was a mechanism to enable staff to speak up safely and without fear. Staff told us they were confident to speak with the nurse, registered manger or provider and felt action would be taken. Staff across all roles were actively encouraged to speak up. The whistleblowing policy was promoted, and staff confidently explained this procedure in line with their service’s policy. Systems were in place gather feedback and records viewed showed concerns were acted on.

People told us they would have no concerns speaking with staff or management if they had any concerns. A relative told us “A general meeting is held every 6 months which residents and relatives can participate in. We had a meeting last Tuesday with about 8 people attended, some relatives and a couple of residents. The manager went through the schedule to explain certain projects and gave attendees the opportunity to raise any other subjects.”

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.

All staff consistently told us that they were treated fairly, respected and without discrimination. Staff gave examples of their reasonable adjustments which had been put in place to support them at work for instance flexible working to support with childcare issues and family emergencies. Some staff had been recruited from overseas, and they had completed all the essential training and with additional support and training around the English culture. A staff member told us, "[Registered manager] helped me to understand meaning of words and ways of doing things like making the bed, cup of tea and language words used.”

Staff felt valued and supported. Staff told us they enjoyed their work and caring for people in residence. Systems in place ensured staff were supported with regular supervisions and received feedback on their performance. They described staff meetings as were positive, and they were encouraged to share ideas.

Staff told us about diversity was celebrated. They spoke about the Christmas festivities and events planned for people, relatives, and the staff party. Special events and festivals were celebrated such as Diwali (festival of light) and had a baby shower for a staff member. Staff also spoke about the support provided for bereavement.

The registered manager told us “We recognise and respect the different religious belief, cultures and celebrate our team by offering special breaks during these occasions. We also have a staff of the month scheme which recognises exceptional work.”

The provider 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 acted on the best information about risk, performance, and outcomes, and shared this securely with others when appropriate.

The provider and registered manager had made sufficient improvements to address the governance issues we identified at the last assessment of the service. Policies and procedures had been reviewed, updated, and shared with all staff. The provider visits were structured, and visits reports were comprehensive and set out actions to address any shortfalls found. The business continuity plan to manage unforeseen events and emergencies was kept under review and was updated as needed.

The provider, registered manager and staff were commitment to delivering of high-quality care. Improved quality assurance systems and processes, and evidence of audits and checks being used effectively to monitor all aspects of the service. We checked a sample of the completed audits, and where issues had been identified action was taken and leaders monitored the progress of improvements. The improved audits in relation to medicines management, premises, equipment and infection prevention and control provided assurances and promoted a culture of continuous improvement. There were audits and checks to monitor if people were treated with kindness, compassion and received safe care.

Systems were in place to ensure staff remained safe and suitable to care for vulnerable people. Staff support systems ensured their training was kept up to date and nurses maintained their professional registration.

Feedback we received from people and relative was consistently positive about the registered manager, nurses and staff, and the quality of care provided. A relative told us, “The service was well led and couldn’t think of anything that could be improved.”

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.

People were encouraged to take part in social activities. There were links developed with local community groups, observe and practice their faith and promoted inter-generational activity. During our inspection visit we saw staff encouraging people to be involved and engaging with people’s personal interests.

People were supported by a variety of health and social care professionals to ensure their needs were met and made referrals to the health professionals when required. The registered manager and nurses had positive relationships with the GP practice, and health care professionals and working relationships helped to achieve positive outcomes for people. Comments received included, “I find the nursing warm and welcoming, staff are smiling and attentive on arrival, they are helping in navigating you to correct person or persons” and “Kenroyal refers their residents to our service, and they are good at providing us with the information we require. We have no concerns with the patients that we are involved with.”

Commissioners, quality monitoring teams and stakeholders told us the registered manager and staff had worked collaboratively, and when issues and concerns had arisen, they had been open, transparent, and responsive to ensure people remained safe. This demonstrated collaborative approach care.

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 provider’s policies and practices were underpinned by best practice guidance. The registered manager and staff recognised the importance of learning lessons from accidents, incidents, audits, and feedback, as an opportunity to improve the service and people’s quality of life. Reflective practice was used effectively, and learning was shared with staff.

The registered manager kept their knowledge and skills up to date. They worked attended meeting with commissioners and forums for registered managers’ and shared learning and best practice with the staff team.

We received positive feedback from health professionals, the local authority and integrated care board (ICB), responsible for monitoring the care for people they have responsibility for, in relation to the provide quality care. The registered manager demonstrated recommendations made by ICB during the latest visit had been actioned for instance, checking and calibration of blood glucose monitors.