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 Requires improvement. 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 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.

Staff we spoke to were able to identify the providers values and vision. We saw staff supporting people in line with these vision and values. For example, we saw staff interacting with people kindly and with compassion, people were given choice over their activities and they told us they were supported well. Comments from people included “Staff are kind” and “Staff help me a lot” Staff told us “We support people to have the best life they can”.

This meant the provider could be assured their vision had been shared and implemented by staff.

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.

We received positive feedback from both people and staff about leaders. A person told us “[registered manager] is good” and “[I like [registered manager] they help me”. Staff told us “[registered manager] is really supportive” and “[registered manager] is always happy to help, you can call them any time”. We were told that the registered manager supported staff to gain further professional qualifications, listened to people’s ideas and involved staff in planning people’s support.

The meant the provider could be assured managers were supporting people and staff with compassion and supported people in line with the provider values.

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

Staff were able to describe how they could speak up and who they could contact if they did not feel listened to. Staff told us the registered manager encouraged feedback. Comments included “[registered manager] always encourages us to speak up and give ideas”.

This meant the provider could be assured leaders were encouraging an open culture that supported staff to speak up when they needed 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 of inclusion within the team. We were told managers treated people fairly and showed flexibility to support staff’s family commitments such as meeting childcare needs and attending personal appointments. Comments included “I can always say if I need support, [register manger] is understanding and shows flexibility”

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.

During our previous assessment we found shortfalls in relation to the governance of the service. During this assessment we found the provider had taken action to address these shortfalls. For example, the provider had a clear business continuity plan, policies were clear and been reviewed. Staff were aware of the contents of the policies and where to find them for reference.

The provider had implemented audits to enable them to monitor quality of support and identify shortfalls, action plans had been developed to ensure action was taken against shortfalls identified and leaders were focused on driving improvement.

The provider had focused on enhancing staff knowledge in relation to the Mental Capacity Act and safeguarding and ensured regular support was provided to staff.

This meant the provider could be assured the registered manger had oversight to ensure good governance and drive improvement.

However, we found some shortfalls in oversight from leaders who had not identified via audits that some practices were not in line with right support right care right culture guidance. For example, risk assessments were not always personalised, and medicines were still stored in a central location. This meant the provider could not be assured people were always supported in line with right support right care right culture guidelines.

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.

We saw the provider had communicated with other professionals to ensure people’s needs had been appropriately assessed. The registered manager had met with other professionals to complete an assessment of people’s capacity and best interest decisions were made in line with legislation.

Staff told us they were in regular contact with professionals to ensure people’s needs were met. This meant the provider collaborated appropriately with others to ensure people were support in line with their needs and wishes and improvements made where needed.

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.

During our previous assessment we found shortfalls in relation to leaning and improvement. During this assessment we found action had been taken to address these shortfalls. For example, we saw areas of improvement and learning were shared with staff during supervision and meetings. The provider demonstrated they had systems to identify learning. Staff told us, “We have been speaking about changes and why we are doing them”. The registered manager told us they had been “focusing on improvements”. This meant the provider was focused on learning and was striving for continuous improvement.