Kaizen Medical Ltd

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

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 inspection for this service since its registration with CQC. This key question has been rated as Good.

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 service 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.

All staff had contributed to the development of the service’s vision and strategy, which was kept under review. Staff described the culture within the service as friendly and professional. The service encouraged learning and development, with opportunities for staff to enhance their knowledge and skills through leadership courses and specialist training.

The service had inclusive leaders 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. Feedback collected by the service indicated leaders were approachable and responsive to concerns raised by staff. Staff feedback also highlighted leaders demonstrated and modelled the values of the service.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. The service had established Freedom to Speak up arrangements with internal and external representatives. Staff understood how to raise concerns and felt able to do so without fear of negative consequences. There was a whistleblowing policy, and staff knew how to access it.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them. Policies and procedures to promote diversity and equality were available and staff also received mandatory training relating to equality, diversity and inclusion. Adjustments had been made to ensure all staff felt valued and supported to carry out their roles, such as flexible working arrangements.

The service 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 act on the best information about risk, performance and outcomes, and share this securely with others when appropriate. Staff took confidentiality and information security seriously. The service had processes to support compliance with information governance requirements, including general data protection legislation (GDPR) and the secure storage of information.

Leaders supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Leaders met with staff annually to complete appraisals and performance reviews. The provider had established governance processes that were appropriate for their service. Staff could access all required policies and procedures. The service provided staff with a detailed employee handbook during their induction. The handbook contained key policies and procedures, and staff were required to sign to confirm they had read and understood its contents. Leaders held daily huddles and full staff meetings every 1 to 3 months. Leaders also shared monthly updates with staff through newsletters. Staff were required to confirm they had read and understood the information and were encouraged to raise any questions or seek clarification where needed.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with external agencies, where required, and collaborated for improvement. For example, staff signposted people to appropriate specialist services to support holistic care and alternative treatment options. The service also sponsored 3 local sports teams to support community involvement. The director of the service was registered voluntarily with the ‘GoodSAM’ app and, at the time of our onsite visit, had responded to 3 local cardiac arrests. (The ‘GoodSAM’ app is a global emergency volunteering and dispatch platform that alerts CPR-trained people to nearby cardiac arrests).

The service 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.

The service identified areas for improvement and discussed these regularly as a team to support ongoing service development and improve the experience of people who used the service. The service promoted a strong culture of learning and reflection. Leaders and staff actively sought opportunities to improve care through research, collaboration, and the sharing of best practice. They valued the views of people who used the service and the community, using this feedback to drive improvement.