Kenilworth Grange Care 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.

This is the first assessment for this newly registered service. This key question has been rated 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 did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

Communication across the home was inconsistent, and staff told us they were not always informed of updates or changes promptly. Several staff described occasions where they became aware of important information only after decisions had been made or changes had occurred. One staff member told us they sometimes “found things out later”, and another said communication varied between teams depending on who was on duty. This lack of consistent information sharing impacted staff confidence and created uncertainty about roles and responsibilities.

Some relatives also felt communication could be improved. They told us informal concerns were not always followed up with clear feedback about what action had been taken. This reduced confidence that people’s views and experiences were fully heard and acted upon.

Despite these concerns, staff were given regular opportunities to discuss their work and speak openly during supervision sessions. Staff described these as supportive and said they were given the tools they needed to develop in their roles. New staff were supported through a structured induction and a “buddy” system that helped model the provider’s values. Staff also spoke with pride about the care they aimed to provide.

However, the inconsistencies in communication and the lack of a fully shared direction across teams meant the provider could not always assure a cohesive culture that focused on continuous improvement and positive outcomes for people.

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.

People and their relatives knew who the registered manager was and told us she was approachable and present in the home. One relative told us, “Her door is always open, I can communicate with her and she knows (Name’s) needs. If she is not around, I can talk to the deputy or one of the nurses. They are all approachable.” Another relative said, “We’re always greeted by the team, the management, there’s always a smile. (Name), the deputy, he really comes round to make sure everything is okay.”

Despite wider communication gaps across the service, staff consistently described the registered manager as approachable, open, and supportive. There had been very recent changes in the senior management of the home. The long-standing deputy manager had been promoted to registered manager, and a new deputy manager had been appointed. Staff reflected on the anxieties associated with changes in management but felt positive about the changes being implemented. One staff member told us, “I think (registered manager) is a great manager, she has got a good way of communicating with her staff and I really appreciate that about her. She is easy to talk to; you can ask her anything or tell her anything.” Another staff member commented, “The manager is good, she listens to whatever problem you have."

The provider promoted a development scheme within the organisation, which the registered manager told us had given them the skills they had needed to develop. Where they identified further areas for learning, this had been provided through mentorship, coaching and further training. The registered manager told us this was ongoing and they felt supported within the organisation. The provider told us other staff in the home had been identified as future leaders and they were being given opportunities to develop in their career.

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

Staff told us they would have no hesitation in reporting poor practice and were confident action would be taken. One staff member told us, "We have to talk and say things. We have duty of candour, and we have to be honest because we have done something wrong and it will be found out." Another staff member said, “I feel confident to speak up. [Registered manager] is quite easy to talk to, so I don’t have a problem voicing problems.”

A staff member who had been appointed to be their ‘Colleagues Voice’ and escalated their concerns or suggestions to the leadership team. One staff member said, "Colleagues Voice, that is [Name], he is very good. He does posts or chats with staff and asks if they have any questions or anything they want to speak about. He is very good for colleagues voice." Another staff member said, "We have a colleagues voice person. When he goes to the meeting, he asks us to tell him if there is anything we want to pass on to the management."

Staff told us there were regular meetings where they could make suggestions that would be listened to. One staff member told us, “I don’t often have concerns to raise, but I find them useful.” Another member of staff commented, "They are fine, people ask questions and they are responded to and some issues are resolved."

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 described an inclusive environment where equality and diversity were celebrated and promoted. One staff member said, "Everyone gets along well and we celebrated Chinese New Year. We have equality days, we try involve everyone in each day of their celebrations."

The registered manager told us of several events that had been organised to celebrate people’s cultural and diverse backgrounds. Where English was not a staff member’s first language, the provider offered training to ensure staff had the best opportunity to develop the skills they needed to communicate effectively with people.

The provider recognised and rewarded staff for ‘going the extra mile’ and people, relatives, visitors and colleagues were invited to nominate staff for their contributions. Individuals were chosen to be celebrated monthly. Staff told us this made them feel good and the registered manager let them know when they had been nominated.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Although a range of audits were completed by both the registered manager and the provider, these systems were not sufficiently robust. Several concerns identified during our inspection, such as gaps in daily monitoring records, inconsistent person‑led care, and shortfalls in how people were listened to, had not been detected through the provider’s own quality assurance processes. This meant leaders did not always have reliable oversight of risks or people’s experiences, and opportunities to prevent poor outcomes were missed. Audits that were in place were not always focused on what people experienced day to day, and the systems used to monitor care were not fully embedded across the service.

Despite these shortfalls, some elements of governance were effective, and we saw evidence of where concerns had been identified and action taken to drive improvement. Information about the planned management of the home each day was shared with the heads of each department at daily meetings. Weekly clinical risk meetings explored people’s needs in more depth, and we saw examples where these meetings had led to improvements.

The service also reviewed falls and other incidents and introduced additional measures when required. During the inspection, the provider strengthened how learning from incidents was shared with the wider staff team.

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.

Relationships with GP services, hospital teams and various health care services were seen to be positive and promote effective joint working.

People in the home were invited to community events such as tea parties and evenings out.

There was a ‘memory tree’ at the front of the building and staff hung engraved plaques with the names of those who had died in the home. The registered manager had made this available to the local community to contribute to if they wished.

The provider focused on continuous learning, innovation and improvement across the organisation and local system.

The registered manager told us how they met with peers from other services within the provider group regularly, through formal meetings, and those sharing experiences helped to drive improvements and learning across the organisation. Similar forums were in place for deputies and other leaders. One staff member explained how learning was shared within the provider group. They gave an example of how staff had received further training in wound care following an incident in 1 of the provider’s other homes.

Both the registered manager and the deputy manager told us how they spent time working in other homes during their induction and were mentored by colleagues, with experience in equivalent roles.

We provided feedback to the regional director and the operational support manager during our inspection. They told us how they would make improvements in the areas we identified that were not always demonstrating personalised care.