Kavanagh Place

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 leadership, management, and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last inspection we rated this key question was rated good, at this inspection the rating has remained 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 71 (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 human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. Staff understood the vision of the provider and how their role contributed to delivering high quality care to people. One staff member told us, “Our slogan is ‘make every day better’ and I try and live it.” The values of the provider were displayed prominently around the home and reflected within the minutes of team meetings.

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. Everyone we spoke with including people, family members and staff told us the management team were open, receptive, and supportive. One staff member told us they could go into any of the managers offices, and they were confident they would not only be welcomed but they could discuss anything that was on their mind. They told us, “[Name] is good. [They] inspire me a lot. [They] are very approachable.” A family member expressed confidence about the management team and about the safety of the service. They commented, “The management is good, I have not had to raise serious issues.” We found the entire management team approachable and receptive to any feedback we shared throughout this inspection.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Policies were in place to guide staff on how to speak up and guidance was well publicised on notice boards around the home. Staff stated they knew how to raise a concern if they were worried about anything and were confident any concerns would be responded to appropriately by the management team. Staff told us, they could raise any issues or concerns with management to improve people’s outcomes. One staff member commented, “I am an advocate for the people who live here. I can raise any issues with the manager.” People and their family members were encouraged to speak up though individual care reviews and provider engagement groups, of which a few people who lived at Kavanagh Place were representatives. A professional described a recent review for a person they had been a part of and told us the management team, “Really listened to the family” when discussing a decision which needed to be made in the person's best interest.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider had clear responsibilities, roles, systems of accountability. 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. However, medication audits needed to be more robust and have more focus on the accuracy of records completed by staff. We identified some people who lived at Kavanagh Place had a learning disability and/or were autistic. The provider had not registered the home with CQC as a specialist service for this population group, however, provider audits assessed people's experiences and quality of care against CQC’s right support, right care, right culture guidance. This provided us with assurance the provider and management team within Kavanagh Place understood how to provide high quality care to this population group.

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. Feedback from partners was positive about multi agency working. One professional told us, “This is my best care home. They care in here and they ring all the time, and we have a great relationship.” There were processes in place to support oversight of people’s needs and ensure appropriate referrals were made where needed. Staff were able to describe the different agencies they worked in partnership with to ensure people's needs were met.

The provider focused on continuous learning, and improvement across the organisation and local system. Quality checks were completed to ensure good governance and oversight. The provider sought views and opinions from staff and people who lived at the home to ensure constant improvement. We reviewed recent surveys. The management team had created 'you said we did' posters which demonstrated the feedback from people was acted upon. Staff meetings, people and family meetings were held on a regular basis to ensure people’s views were heard and acted upon. One family member told us, “If you have any problems you can talk to the manager, and they will sort it out.”