Kingly Terrace

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 Outstanding. At this assessment 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 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 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 provider promoted an open and transparent culture. Staff described the management team as approachable and told us they felt comfortable raising concerns, seeking advice and sharing ideas.

The staff and management team demonstrated values of kindness, respect, honesty and accountability in their day-to-day interactions. People and their relatives consistently told us staff were caring and compassionate.

During the assessment, we observed people being treated with dignity and respect, and the management team welcomed feedback in an open and positive manner.

The manager had already started addressing areas requiring improvement. For example, improvements had been made to medicines management, demonstrating a positive direction of travel.

The provider worked closely with the manager and staff to promote a positive culture that placed people's wellbeing at the centre of the service.

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 provider understood their legal responsibilities, kept up to date with relevant guidance, and submitted statutory notifications to CQC when required. There was a new manager in post who was in the process of registering with CQC.

The manager was visible, approachable, and knowledgeable about the people using the service and the day-to-day running of the home. They demonstrated a strong commitment to providing a welcoming and supportive environment for people and staff.

People and staff spoke positively about the leadership team. They described the management team as approachable, supportive, responsive, and visible within the service. Senior leaders also visited the home regularly to provide oversight and support.

The provider fostered a culture where staff felt they could speak up. The provider had a whistleblowing policy and procedure in place for staff support and guidance.

Staff new how to raise a concern outside of the organisation if they needed to.

Staff told us they would be confident to speak up if they had concerns and they felt they would be listened to.

A whistleblowing policy was in place and available to staff. Staff demonstrated an understanding of the procedure and told us they felt confident to raise concerns without fear of negative consequences.

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 valued diversity in their workforce. There was an inclusive and fair culture which meant equality and equity for people who worked for them.

The provider had an equal opportunities policy and employed a workforce that reflected the diversity of the local community. The provider ensured a fair recruitment process with equal opportunities for career progression. Staff work patterns were adapted to support personal circumstances where needed.

Staff had received training in equality and diversity, helping to prevent discrimination and promote a respectful workplace.

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.

Systems and processes were in place to monitor the quality and safety of the service. However, they were not always effective at identifying and addressing areas that needed improvement.

During the assessment, we found gaps in recruitment records, supervision records, and Mental Capacity Act documentation. These issues had not been identified through the provider's own quality assurance processes. Although people were meeting their fluid intake targets; there was no record of drinks being offered between around 6:00 pm and 7:00am on any of the fluid charts we reviewed. The provider's audits had not identified this gap in recording before the assessment. These findings demonstrated that governance systems had not consistently identified and addressed documentation shortfalls before the assessment.

The provider and management team responded positively to the feedback given during this assessment. They were open about the areas that needed improvement, accepted our findings and took action to address some of the issues before the assessment ended. This showed a willingness to learn and improve.

The provider had business continuity plans in place to support the safe running of the service in the event of an emergency. The home also benefited from oversight and support from the wider organisation, which contributed to the ongoing sustainability of the service.

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.

The provider understood the importance of working collaboratively with external partners to support positive outcomes for people. They worked closely with healthcare professionals, including GPs, district nurses and phlebotomists, to ensure people received coordinated care and appropriate support when their needs changed.

The home is part of a larger provider group, which holds regular managers' meetings across its services to share learning, good practice and service improvements. The manager also told us they plan to join the local registered managers' network and attend local forums to build relationships, share learning and keep up to date with best practice.

Relatives told us they were kept informed about their family member's care and were involved in care planning and decision-making where appropriate, supporting a joined-up approach to care.

The provider promoted learning and improvement across the service. However, they had not always embedded learning from previous quality monitoring into practice, as some areas requiring improvement remained.

The provider engaged with external oversight and demonstrated a willingness to learn from feedback. Records showed that previous quality monitoring had identified areas for improvement, including Mental Capacity Act documentation, meaningful activities, and recruitment records. During our assessment, we found that further improvements were still needed in these areas, indicating that changes had not yet been fully embedded into practice. However, the provider and management team responded positively to the findings, acknowledged where improvements were required, and demonstrated a commitment to implementing the necessary actions to improve the quality of the service.