Caremark Kensington

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.

The service was in breach of legal regulation 17 in relation to governance at the service.

This service scored 62 (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 told us the culture within the service was positive, inclusive and compassionate, which helped build trust and understanding between the service and people using it. Staff and the management team demonstrated their understanding of equality, diversity, and human rights. These were actively promoted and the causes of any workforce inequality were quickly identified, and action was taken to address the issues.

People, their representatives and staff told us they felt the service was well managed and said the management team were very approachable and supportive. A person using the service told us, “If I phone the agency they answer within one minute. I think they are very good.”

The registered manager and senior staff understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. These leaders strived to lead effectively, with integrity, openness and honesty.

The registered manager and wider management team demonstrated dedication and commitment to working closely with staff, healthcare professionals and people who used the service. They cared about the people using the service, as well as the staff, and were working hard to address shortfalls to ensure everybody working within the service, or using it, benefitted from a good quality service.

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

The service had effective systems and processes in place to help ensure people knew how and felt confident to speak up, raise concerns and whistle-blow, without fear of retribution. We saw the service had a whistleblowing policy, which was regularly reviewed and discussed with staff.

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 management team provided effective and proactive ways to engage with and involve staff, with a focus on hearing their voices and listening. Staff told us they felt supported to develop their skills and knowledge.

All staff told us the registered manager was approachable and supportive. Most staff said they had regular 1-1 supervision meetings and appraisals, as well as team meetings and spot checks. A member of staff told us “I feel able to speak to the managers in office and I aways get a good response. The office staff tell me everything I want to know; I call them and it’s sorted out.” Other staff told us they attended monthly staff meetings, where issues and concerns raised were listened to and acted upon.

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.

External partners spoke positively about the working relationship they had with the service. They confirmed the registered manager was responsive and keen to work collaboratively with them to address any shortfalls and make improvements where needed.

People’s care records demonstrated that people were referred to appropriate healthcare professionals when needed. Information and guidance from external healthcare professionals was shared with care staff to help ensure consistency in providing care and support.

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.

External partners spoke positively about the working relationship they had with the service. They confirmed the registered manager was responsive and keen to work collaboratively with them to address any shortfalls and make improvements where needed.

People’s care records demonstrated that people were referred to appropriate healthcare professionals when needed. Information and guidance from external healthcare professionals was shared with care staff to help ensure consistency in providing care and support.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always actively contribute to safe, effective practice and research.

The provider’s systems and processes to help ensure that lessons were learnt when things went wrong were not always effective or reliable. We saw that issues were raised and discussed in team meetings, as well as during staff’s supervision sessions. However, we identified that lessons were not being learned from mistakes and shortfalls in the past and appropriate action was not being taken in a timely manner to ensure improvements were made and maintained.

We saw that audits were being carried out for aspects such as medicines administration and call logs, as well as people’s care records. We also saw that, where necessary, care workers were asked to attend additional 1-1 meetings to discuss any areas for improvement identified during these checks and determine whether refresher training or other support was needed to develop their knowledge and practice. However, despite this, we found there continued to be recurring issues.