Kent PBS Service

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 Inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to good governance.

This service scored 25 (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 vision and strategy, but this was not demonstrated in practice. They did not have a culture focused on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

These values were not reflected in leadership, oversight or organisational culture. Relatives, professionals and leaders identified concerns relating to accountability, communication, escalation of concerns and oversight of care. We identified a closed culture at the service (a closed culture is poor culture that can lead to harm, including human rights breaches and abuse).

The provider had failed to ensure people were at the heart of their service. People had been failed by the provider, which had a major impact on their lives: people had been harmed. Leaders were aware of several concerns but had not always acted promptly or effectively to address them. For example, where people self-neglected or placed themselves or others at risk of harm, these were not escalated in a timely way. The provider failed to establish a culture that consistently promoted safety, learning and accountability.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

Significant concerns relating to risk management, safeguarding, medicines governance, care planning and training had not been identified through routine management oversight prior to inspection. Leadership arrangements were not sufficiently effective in assuring the quality and safety of care. Where significant concerns had been raised about the safety of people there had been increased management oversight, but this had been ineffective and there continued to be profoundly unsafe care practices which put people they supported and staff at risk of harm.

People stated they could speak up, but there was no evidence of this happening.

Whilst staff stated they could raise concerns to managers and to external bodies, people received a standard of care that increased self-neglect and where individuals conditions had deteriorated without being appropriately escalated. Repeated concerns identified through external agencies, relatives and inspectors indicated that mechanisms for identifying and escalating concerns were not always effective in practice. For example, multiple staff raised concerns about the safety of certain service users to inspectors, but these concerns had not been communicated to other professionals involved in their care. The provider could not demonstrate that concerns raised internally and externally consistently resulted in timely and sustainable improvements.

The provider did not value diversity in their workforce. They did not work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Certain staff worked in circumstances where they experienced significant racial abuse and threats directed at them and their families. There was only limited guidance in place, and the provider had not recognised how deeply unacceptable it was to place staff in a position where they would be exposed to this.

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

We identified widespread concerns relating to medicines management, safeguarding, risk assessments, staff training, incident management, care planning, self-neglect, nutrition, quality assurance, and record-keeping affecting multiple people.

Records were not always accurate, consistent or regularly reviewed. For example, there was very limited information recorded about how staff supported one person, meaning the provider could not be assured if the support for this person was appropriate or even that they were working. Significant risks identified within care plans were not regularly monitored or reviewed. Quality assurance systems failed to identify and address many concerns before inspection.

The provider could not demonstrate that governance arrangements effectively recognised risks, monitored performance or ensured people received safe and high-quality care. We observed there had been a significant volume of medication errors over a period of 10 months until this was identified by the provider through their own mechanisms. They had not identified that the knowledge and practice of staff was poor in many areas.

The provider did not understand their duty to collaborate and work in partnership effectively, so services work seamlessly for people. They did not share information and learning with partners or effectively collaborate for improvement

Although there was some evidence of collaborative working, professionals raised concerns regarding implementation of agreed actions, follow-up arrangements and the provider's response to identified risks. Partnerships did not consistently result in effective action to improve outcomes for people. Stakeholders raised concerns that areas for improvement were not consistently addressed or acted upon, and that where people made unwise or unsafe choices no action was taken by staff to safeguard people. Despite significant work by partners around strategies to support people in having the best quality of life, these had not been meaningfully embedded in practice.

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.

There was no clear commitment to improvement, and relatives expressed deep upset and trauma about the difficulty at affecting meaningful improvement in people’s outcomes. One relative told us “I don’t feel listened to. When I raise issues, they don’t listen or act on what is said and they aren’t proactive. I’ve been screaming into the abyss, modelling techniques but they haven’t been followed. It’s been very traumatic”.

There had been failures in monitoring which had not identified unsafe or undignified care practices, and at the time of our inspection people continued to be supported by staff who did not have the training or knowledge they required to support people safely. The recurrence of similar concerns across different people and services indicated that learning was not effectively embedded. Improvements were often reactive rather than proactive, and the provider could not demonstrate a sustained culture of learning and continuous improvement.