Keneydon House

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

The provider had governance and assurance systems in place although some of these required improvements. These included audits and checks on the safety and quality of the service. There had been changes in management and the home manager in post was to begin the process of registering with CQC. The provider and manager were keen to make changes to ensure they promoted a positive culture of support, learning and development. The management were responsive to issues raised during this assessment. The manager needs to ensure they are clear about which incidents to report as 2 incidents had not been reported to safeguarding. They also need to ensure that information is followed up i.e., blood test. Recruitment processes require improving to ensure information is followed up and recorded. Management and staff worked in partnership with the local authority and health professionals to share learning and help improve the quality of people’s experiences. Positive feedback was received from health professionals and the local authority about the management and staff approach to collaborative working to improve the quality of care provided.

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 manager had taken steps to ensure staff understood and demonstrated the services vision and culture in the care and support they provided to people. Staff told us there had been a change in culture at the service since the manager started and this had greatly improved, and they were working better as a team. A staff member said, “Its lovely. I don’t feel like I come to work every day. Seeing how happy residents are; we laugh and sit talking. The residents are all lovely.” The manager spoke passionately about their commitment to learn and drive improvement within the service.

There were training, policies and procedures in place to support staff in being the best they can. A vision of looking to make things better for the people in the service.

Staff felt supported in their role by the manager. A staff member said, “The manager is always available for support and works alongside us.”

There was no registered manager in post at the time of this assessment. The manager told us they were going to submit an application to CQC to become the registered manager. However, there has been no application submitted at the time of writing this report. The manager was supported by regular visits from the provider or their representative to look at the quality of the service. The manager understood their roles and responsibilities. The manager was passionate about improving the service and recognised that there were areas that still needed further improvement.

All staff felt supported by the manager and felt they could raise concerns and they would be acted upon.

Systems were in place to ensure staff had the opportunity to voice their views and opinions in an open and supported way. For example, daily handovers were carried out. Whistleblowing and safeguarding procedures were in place, well signposted within the service and understood by staff.

Staff said they were confident the manager and provider would support them by making reasonable adjustments to accommodate any additional needs they had.

There were processes in place to ensure staff were treated fairly and equally and their rights were upheld. For example, there was an equality and diversity policy in place.

The manager told us it is important to have good governance processes in place to maintain and developing the service. The manager said, “It’s so important for me to know what’s going on in the service and how people are feeling. That way we can sort things out and keep moving forward.” The manager told us they were supported by a representative of the provider that visits the service regularly to oversee the quality of the services provided and ensure that action is taken to address any shortfalls and provide them with any support required.

We found audit systems to assess, monitor and improve the safety and quality of the service were not fully effective. The safeguarding policy had no date of issue or review date to ensure it remains in date. We also noted that there had been 2 safeguarding incidents that had not been reported. We discussed this with the manager to ensure they were clear about what incidents should be reported. Risks, although identified, lacked detail on how to manage and reduce the risk. Care plans also lacked detail, although the manager had started to take action to provide more detailed information in people's care plans and on the identified risks to ensure that staff had the information available to fully meet peoples care, support and safety needs. Recruitment procedures needed to be more effective and ensure the provider is following their own policy to ensure they have all the information needed to make judgement on the persons suitability to work with people. We found that a number of the audits that had been carried out did not contain full information and some had become a tick box exercise. For example, the infection control audit ticked the box to say records had been looked at, although there was no information about which records were looked at and what did they show. Action was being taken to address the shortfalls that we identified during this assessment by the provider and/or the manager.

Staff were able to demonstrate how they had involved other professionals in people's care including health referrals, care reviews and multi-disciplinary team meetings with other health professionals.

The manager told us they were engaging with the local authority and other health and social care professionals to address concerns and demonstrate how improvements were being made.

Following their contract monitoring visit by the Local Authority an action plan had been created which had identified some areas for improvement. The manager had started to address the areas identified in the monitoring visit.

The provider had processes in place to seek support from other health professionals and work in partnership to improve people's care. Records showed that further health and care support had been provided for example: dental, dietitian and chiropody services had been to visit people in the service and had provided additional information to support people with their health care needs.

Staff understood their role in completing forms following an accident or incident, however, some of the staff were unsure of the steps which followed e.g. sending a referral to other professionals for additional support. All staff we spoke with felt confident that the manager had dealt with them appropriately as changes to people care had been made. Staff informed us that daily handovers and staff meetings were used as an opportunity to update one another about, accidents, incidents, notifiable events and how people were doing. One staff told us, "Incidents and accidents are discussed in meetings and any findings shared. The manager is good at keeping us informed of any changes to practice or peoples care needs."

The service had started to put systems and processes in place to continuously learn and improve. They had started to ensure relatives and staff were asked for their feedback and the service had started to analyse and action this feedback. The manager had analysed incidents and accidents to identify themes or trends to reduce the risk of avoidable harm.