Kemfa Services Limited

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 improvements had been made, and 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.

The service was previously in breach of the legal regulation in relation to good governance. Improvements were found at this assessment and the service was no longer in breach of this regulation. Robust systems had been established to effectively monitor and manage the quality of the service, encompassing safeguarding, auditing, medicines, and staffing. The leadership team had demonstrated a strong commitment to learning from past challenges and had implemented a clear strategy for ongoing improvement and development.

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. Improvements had been made to the shared direction of the service such as the involvement of staff in discussions about good practice, lessons learnt and improvements.

The vision and values of the service were clear and promoted people’s rights, choices and independence. This was outlined in their statement of purpose. The registered manager and staff actively sought and acted on the views of people and their relatives through their visits, reviews and telephone calls. A family member said, “I am not sure of the name of the manager, but I have spoken to [name of office staff member] quite a few times. I feel like the overall management is better than it used to be.” Another family member told us, “They have improved a lot over the past year.”

Staff were positive about working for the service. Comments included, “There is a positive culture where staff are encouraged to raise concerns and contribute ideas” and “The morale among staff is positive; we work well as a team and support each other.”

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 registered manager had the skills and experience to lead effectively. They were open, honest and inclusive in their working approach. They had learnt lessons from the previous assessment and had been active in making the necessary improvements to ensure people and staff had a quality service to use and work for.

There was a strong management structure with clear roles and responsibilities which had helped to promote an open and transparent culture of collaboration and learning. There was clear accountability and decision-making processes to ensure the overall quality of the service continued to improve. There was a focus on better outcomes for people, with dedicated managers to oversee areas such as safeguarding and complaints and quality and compliance monitoring.

Staff told us there was a good system in place for support and advice when they needed it, during office and out of hours. A staff member told us, “Overall, I find Kemfa Services Ltd to be a supportive and well-led organisation. The training, communication, and team culture give me confidence in my role and enable me to deliver good care to the people we support.”

There were improved systems to gather, record and act on the views and concerns of people and their relatives. There was an openness to address concerns and deal with them respectfully, directly and actions were taken in response, demonstrating a commitment to resolving matters effectively.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider’s whistleblowing policies and procedures had been updated and available to staff. Staff and leaders actively promote staff empowerment to drive improvement. They encouraged staff to raise concerns and promoted the value of doing so. Staff were confident that their voices would be heard. A staff member told us, “Managers are approachable, and feel I can speak up without fear of negative consequences.” Another staff member said, “I feel confident to raise any concerns as the manager is very approachable and easy to talk to.”

Staff supervisions and meeting minutes evidenced that staff had been given the opportunity to speak up and this had helped to drive improvement. Investigations were undertaken effectively, sensitively, and confidentially and lessons shared as a result.

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 registered manager had developed an inclusive workforce and recognised the value of diversity amongst the team. There were enough staff who worked well together, with flexible rota and working arrangements. Staff members’ individual needs and circumstances were considered, and any reasonable adjustments made to ensure there were no barriers to them working for the service. A staff member said, “The company is supportive of different cultures, and we do have training on equality and diversity.”

The provider promoted equality, diversity and inclusion. Staff had undertaken training to raise their awareness and knowledge. A staff member told us, “About equality of opportunity. I have been treated nicely and spoken to with respect. I have opportunity to speak up during our monthly meetings and during supervision and training.”

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.

At the last assessment, systems for the effective governance and oversight of the service were not in place. These included assessing people’s needs and risks, planning their care, safeguarding people, the administration of medicines, call times and audits of the quality of care provided. Legal and regulatory requirements were not consistently met, such as failure to submit statutory notifications. These are notifications the provider must make to the CQC for certain issues such as safeguarding concerns or serious injuries.

The provider had made significant improvement in the management and oversight of the service. There were now effective systems and processes in place in all areas of the service including assessments, care planning, safeguarding, complaints, medicine administration and audits of quality and safety. All records were available to us as requested.

Incidents, accidents and complaints were logged and fully investigated. We saw a step-by-step approach to managing and investigating these and lessons learnt as a result. Audits were detailed and provided a clear overview of all aspects of the service so the quality of care could be monitored. Risks to people’s health and safety were well managed. Care plans and risk assessments now provided a person-centred account of people’s associated risks and guidance for staff in how to mitigate those risks. People and their relatives were involved which enabled them to be in control of their care arrangements

The provider used an electronic management system to provide better oversight of the service. This included care assessment and planning, medicine management, and administration and monitoring of rota and visit times. Staff had an application on their phones to access up to date information about people’s needs and circumstance. The live system provided information about staff rotas, when and where staff were on their visits and, any issues regarding staff being late or not available. There were alerts on the system if staff were not where they should be at the given times. All managers received these alerts so they could be dealt with quickly. This had resulted in a reduction on late or missed calls and made communication more efficient. People and their relatives reported better outcomes as a result.

There was an effective process in place for the induction and supervision of staff. Team meetings had been increased and were inclusive and meaningful. Sessions included learning from mistakes, discussions about roles and responsibilities, safeguarding and refresher training identified through the ongoing monitoring of the service. Staff feedback was positive about the management and support they received to do their job effectively. There was a robust process in place for the safe recruitment of staff.

The registered manager understood their responsibility under duty of candour to be open and honest and investigate when things went wrong. Sustaining new systems and processes would need to be monitored effectively to ensure they were well maintained and met the developing needs of the service. The registered manager was clear on their legal and regulatory requirements and made notifications to the local authority and CQC where appropriate and in a timely way.

The provider understood their duty to collaborate and work in partnership, by sharing information and learning with partners. They worked effectively with health and social care professionals to get the best care for people they were supporting, such as identifying when people’s needs changed or increased. They were responsive when people were discharged or were admitted to hospital. Staff enabled people, where it was part of their care arrangements, to access their local communities to enjoy the facilities available.

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.

The provider had been open to advice, support and learning in making the improvements to the service. The investment in the implementation of an electronic system enabled the registered manager to have access to real time information and live data about all aspects of the service. This helped to audit records and documentation quickly and easily.

The registered manager was proactive in researching best practice and was solution focussed on providing good care to people. Effective systems and processes for the management of the service, clear roles and responsibilities, the electronic call monitoring system as well as the change to the culture of the organisation had been implemented and were positive examples of this.

Staff were encouraged to develop their skills and learning so they could provide the most appropriate care for people using up to date best practice guidelines. Staff were involved in discussing good practice, trialling new ways of working, analysing success and implementing new systems. People had better outcomes as the service met their needs and was more effectively managed. People and relatives told us they would recommend the service to others.