Kingswood Manor

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 found a breach in relation to the governance and management of the service. At the last inspection, there was a lack of effective governance systems in place to enable people to receive good quality care. Concerns identified previously with regards to the management of medicines, fire safety arrangements, premises and care and treatment had not been fully addressed. Governance arrangements failed to ensure effective and timey action was taken to ensure compliance with the health and social care regulations in these areas. This was despite the provider, providing assurances that sufficient improvements had been made. The culture of the service was positive, although some staff had mixed opinions about staff morale. Regular staff meetings and staff supervision took place. Staff told us they felt able to raise any concerns with the manager and provider. They said they felt supported in the workplace. Staff were aware of the whistleblowing procedure and what action to take if they had any concerns about the service or people’s care. Staff told us they worked well as a team and co-ordinated people’s care within the home’s community. The manager liaised with the Local Authority in respect of any quality or safeguarding concerns. Multi-disciplinary meetings took place regularly with other health and social care professionals in support of people’s health and well-being and internal meetings took place to share updates on people’s progress. Care staff told us learning was shared at staff meetings when required. It was difficult to determine what continuous learning with regards to clinical care was shared across the nursing team as during our inspection we identified improvements were needed in respect of medicines and wound management. Ongoing shortfalls in medicines management, care planning, wound management, fire and premises safety demonstrated a lack of continuous learning and improvement in these areas.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff told us they felt supported but there were mixed opinions over the current status and morale of staff. Comments included, “It is quite stressful at the moment, so has an effect on everyone but everyone tries to keep going as usual as best as possible”. Another staff member told us, “Staff are generally happy, I am really happy here". During our visit, we found the culture of the service to be warm and friendly. People we spoke with and their families confirmed this. Staff were kind and caring and the atmosphere was relaxed and welcoming.

There were processes in place such as staff meetings, supervision arrangements and senior management meetings to share and disseminate information about the service, its vision and culture.

Staff told us they felt supported by the manager and provider. One staff member said, “Managers always ask if we need any support. I find them helpful. Feel supported by managers, can go to them with any problems”. Another said, “Regular supervision with manager, last one was last month. Managers are very supportive and yes can go with any concerns”.

There was a management structure in place to support the running of the service. This included the manager, the regional support manager and deputy manager who were on site. A regional manager had oversight of the service and spent part of the working week in the service supporting the manager and other staff.

Staff told us they felt confident speaking up. They were aware of the whistleblowing procedure and what action to take if they had any concerns.

There was a whistleblowing policy in place to guide staff on how to raise concerns. There was a safeguarding and complaints policy in place to guide staff, people using the service and others, on how to make a complaint. Staff meetings took place, and staff were encouraged to speak up and share their views and suggestions

Staff told us they felt the provider was a fair employer. Staff told us they felt supported by the manager and other senior managers involved with the service.

There were appropriate policies and procedures in place to support workforce equality, diversity and inclusion in respect of staff recruitment, training, working arrangements and well-being. Equality and Diversity was discussed during staff meetings were appropriate with staff suggestions requested for where improvements could be made. Staff received training in equality and diversity.

Staff felt the service was well managed. However, we found improvements to the management of the service were still required.

At the last inspection, the provider failed to ensure effective governance systems were in place to enable people to receive good quality, safe care. At this inspection, concerns identified at the previous inspection with regards to the management of medicines, fire safety arrangements, premises and care and treatment had not been fully addressed. It was clear the provider’s governance arrangements had failed to ensure effective and timey action was taken to ensure compliance with the health and social care regulations in these areas. This was despite the provider, providing assurances that sufficient improvements had been made. Improvements had been made with regards to the robustness of staff recruitment. However, the provider’s governance arrangements had not always identified that gaps in employment were not always investigated or that some contracts of employment were signed and dated before staff had applied for their job. This did not make sense. Yet these discrepancies had not been explored or addressed by the manager or provider. The governance arrangements in place had not identified or ensured the environment in which people living with safe, suitable and dementia friendly or that people had access to tools to enable them to communicate effectively. The systems in place had not identified that care plans still required further development to ensure staff had access to sufficient and clear information about people’s needs and risks.

The service worked in partnership with a range of other health and social care professionals, including the Local Authority.

Staff told us they had handover meetings with nursing staff and regular staff meeting in which information about the home’s community and the management of the home was shared. Staff at the home were involved in regularly multi-disciplinary meetings in support of people’s needs.

Partners raised no concerns in this area.

There were both external and internal processes in place to share information and work in partnership together such as multi-disciplinary meetings, GP ward rounds and internal staff handovers and meetings.

Care staff told us learning was shared at staff meeting as and when required. Records confirmed this. It was difficult to determine what continuous learning with regards to clinical care was shared across the nursing team. and during our inspection we identified improvements were required in respect of medicines and wound management. Ongoing shortfalls in medicines management, care planning, wound management, fire and premises safety demonstrated a lack of continuous learning and improvement in these areas.

There were processes in place for service users and their families to be involved in resident and relatives meeting to discuss the service. Professionals were also asked for their feedback. There was little evidence of any processes in place to encourage and facilitate innovation or contribute to research or best practice.