Kemfa Services Limited

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 key question of Well-led was rated as good at our last assessment. At this assessment the rating had deteriorated and the key question of Well-led is now rated requires improvement. During our assessment of this key question, we found systems and processes were not effective to ensure good governance and oversight. The provider did not independently identify risk which impacted on people’s safety and welfare. The approach to learning, improvement and innovation was inconsistent across the service and did not include the measuring and analysis of outcomes and impact. Legal requirements were not consistently met, such as the systematic failure to submit statutory notifications. During our assessment of this key question, we found concerns about the oversight and management of the service which resulted in a breach of the Regulation Good Governance. You can find more details of our concerns in the evidence category findings below.

This service scored 39 (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 failed to ensure they developed a system and culture whereby people consistently felt valued and respected. The provider failed to address concerns and ensure people, and their loved ones, were involved in the service in a meaningful way. There was a poor culture within the service, which did not promote learning and improvement. The provider had not ensured systems and processes were in place to ensure people received safe care and treatment. The provider had no oversight of the effectiveness of systems and processes. There was no process to ensure supervisions, team meetings and surveys were meaningful and effective.

The provider failed to address concerns and ensure people, and their loved ones, were involved in the service in a meaningful way. Improvements were required to demonstrate consistently capable leadership that listened and included others in meaningful processes. The registered manager failed to lead by example, and ensure risks were well managed. There were significant shortfalls relating to incident investigation, and risk mitigation which were not addressed by the management team. Concerns we raised to the management team were not known or identified through their processes and systems. There were no clear roles defined by the management team. The registered manager told us that they would be making changes to the management team which would give the provider better oversight of the service.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider was asked to share with us staff feedback they had gathered to demonstrate partnership working or how the provider values the views of the staff team. However, the provider did not share evidence of staff feedback with us or how they had analysed staff views to make improvements. The registered manager told us staff had one to one supervision and the opportunity to speak up, however we found not everyone had regular supervision.

The registered manager told us that they completed audits on the quality of the service. Our assessment of these audits found them to be of poor quality and failed to identify the widespread concerns we found. The registered manager told us they had found it difficult to have oversight of the service and this is what has led to the decision for change in the management structure. We identified the registered manager had not reported all notifiable incidents to the CQC as legally required. The registered manager told us these incidents had not been identified as reportable. Feedback from the registered manager did not provide assurance or evidence of robust, effective or well-embedded governance and oversight measures.

Systems to ensure compliance with legislation and the provider’s internal governance were poor. There was a lack of oversight of the service. Governance processes were not well established and monitored to ensure safe and good quality care. There was no evidence of effective provider oversight in areas including assessments, care planning, safeguarding. medicines and audits. Where audits were in place they were insufficiently detailed, and care plans lacked detail to mitigate risks. Legal and regulatory requirements were not consistently met, such as failure to submit statutory notifications. These are notifications the provider must make to the CQC for certain issues such as safeguarding concerns or serious injuries.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

There were significant and widespread concerns identified during this assessment. The manager and provider could not evidence that action had been taken to learn and improve the quality of the service prior to our assessment. There was not a consistent approach to measure outcomes and impact for people. The provider failed to ensure a robust and effective system was in place to record, review and manage complaints. During our assessment, the registered manager told us they had identified there were no processes in place to analyse complaints and they were developing systems to manage this. Therefore, the provider had no oversight of complaints. Furthermore, they had failed to have effective systems to identify where complaints met the threshold for reporting to safeguarding and CQC. Our audit of the provider’s complaints log found they had listed these examples as ‘complaints’ and their systems had failed to identify them as safeguarding concerns. For example, poor spacing of care calls leaving a person in bed for too long. It was alleged the person was left in bed for long periods of time in a wet incontinence pad which had caused damage to their skin. This would be reportable under safeguarding. The provider received another complaint that a care worker had not attended to a person during a night call. The provider removed the care worker however they failed to have effective processes to differentiate this from a complaint to a safeguarding as an allegation of neglect.