Archived: Keiron Starns Care Agency

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 Good. At this assessment the rating has changed to Requires improvement. 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.

This service scored 61 (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 had a vision for the service of respect and enablement which was shared with staff at their induction. We saw the registered manager and staff communicated well along with people they supported and external professional bodies in line with their vision. Staff we spoke to told us the support they offered was in line with the provider’s vision.

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 both staff and people demonstrated the registered manager was a compassionate and inclusive leader. Staff were happy in their job. Comments included “This is by far the best job I’ve had” and “[Registered manager] is open to new ideas”. They had an honest an open approach to our findings and feedback.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider had a whistleblowing policy which had been reviewed. Staff told us they were confident if they raised a concern the registered manager would take the appropriate action. Staff felt the manager was approachable and supportive. Staff knew how to raise concerns. Although staff were not familiar with the term freedom to speak up. They said they felt able to speak up, that the registered manager was approachable and they would feel confident raising concerns. Staff knew who they could contact if they felt their concerns were not being listened to.

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. Staff were positive about the culture within the team. Staff told us “We are never made to feel we can’t do something” and “The registered manager is very flexible”.

The provider did not have clear responsibilities, roles, systems of accountability or good governance. They did not act on the best information about risk, performance and outcomes. Policies did not always contain up to date information that was in line with current national guidance and best practice. For example, the restraint policy contained information on how to restrain a person which was not in line with national guidance. The service at the time of our assessment was not supporting anyone who required restraint.

There were several copies of the business continuity plan and whistleblowing policy. This caused confusion over which version staff were required to work from. The infection control policy referenced wearing gloves, but this was not in line with current best practice. This meant the provider could not be assured that staff had the correct information and guidance to deliver safe care and support. Staff had not read and understood all policies and documents. There were missing signatures on the sign sheets. We saw that the staff member who audited financial transactions had not signed the financial policy. Further, staff had not signed the Mental Capacity Act policy. This meant that the provider did not have effective auditing and monitoring systems in place to ensure policies were relevant, contained current information or that staff were aware of these and working in line with them.

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 maintained effective communication with other healthcare professionals to ensure needs of people were met.

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.

The provider did not have varied and effective audit systems to enable them to identify areas for improvement. The only audits completed were regarding financial transaction and a monthly medicines quantity check. There were no infection prevention control audits undertaken despite the service providing support to a person with complex personal care routines. The provider did not audit temperatures of hot water outlets and there were no audits of legionella testing.

The provider completed visual checks on staff interactions with people they supported, and these were referred to as staff supervision. However, they did not contain details of conversations, improvements or areas of development.

During our assessment we highlighted areas which required improvement. This meant the service was not performing well in some key areas such as governance. The provider could not be assured that lessons were being learnt to contribute to continuous improvement. The registered manager completed an action plan following our feedback to identify and action areas for improvement. The registered manager took immediate action on some areas we identified and was positive in their approach to making improvements.