Kingsbury Court

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 registered manager ensured an inclusive and positive culture in the home and took action to continuously improve the service. Staff supported people in a person-centred way. Leaders supported staff and collaborated with partners to deliver care that is safe, integrated, person-centred and sustainable, and to reduce inequalities. At the last inspection in August 2022 the provider was in breach of regulations because they failed to operate effective governance systems and to continuously improve the service. The registered manager made significant improvements to the governance and communication in the service. The provider was no longer in breach of regulations at this assessment. There were now good quality assurance and auditing systems in the home. The management team used those systems effectively to drive continuous improvement. The registered manager ensured audit findings and lessons learnt were discussed with staff. Staff had opportunities to attend a wide range of meetings and training sessions which improved communication in the service. The nursing and senior staff team met regularly to discuss and address clinical risks. The home had a supportive, empowering, and inclusive culture where equality and diversity of the people receiving care, as well as the staff team was respected and celebrated. Staff felt supported and listened to by managers and commented teamwork had improved. Leaders were approachable and worked in an open and transparent way.

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.

Staff and leaders shared common vision for the home and the same values. Staff told us what their aim was, “To provide people with the best care possible.”; “To work well as a team and to make people feel this is their home and they can do anything.”

The home had a clear statement of purpose and description of the values which the staff team aimed to work in line with. The values included dignity, quality, ambition, caring, being inclusive and integrity.

Staff valued the management team and felt they were approachable and competent leaders. Staff told us, “[The registered manager] is the best. He listens. He’s amazing, he’s always around, he’s fun when he needs to be, works really hard.”; “The culture here has really changed. A caring job needs heart. I want [staff] to be happy and progress. The residents are the most important thing and staff know that. You can see the light in them when they see staff approach.”

The way the managers made themselves available and ensured good governance and oversight of the day-to-day running of the service was recognised by people and their relatives. A relative commented, “In all the time Mum has been here this has been the best manager. He has really turned this round in the past year. He’s taken more time in employing staff, he promptly responds to issues and his door is always open. He also took on a clinical lead who is so knowledgeable. The nursing team are the best in 6 years. It’s a big relief and gives me piece of mind.” The managers created inclusive culture and supported staff on a daily basis.

Staff knew how to raise concerns and felt comfortable to do so when needed. Staff told us, “I would call the anonymous number if I felt someone was at risk.”; “I would have no problem raising concerns and keep going further (to more senior managers) if nobody was listening to me.”; “You can just walk in and talk to [the managers]. They acknowledged what you say, and they do something about it.”

The provider had clear whistleblowing policy in place and information for staff on how to raise concerns.

The management team created and supported an inclusive, respectful culture in the home and within the staff team. One staff member said, “Everyone I’ve worked with have been so helpful.” Staff told us how their individual needs around protected characteristics were respected. For example, some staff had individual risk assessments in place and reasonable adjustments were made to enable to them to fulfil their roles. Staff also told us, “I’m allowed to wear (pointed at jewellery of cultural relevance). They know that is important.”; “If I want to have a meal, they will make sure I don’t have [certain foods], colleagues who don’t eat [these foods] are catered for.”

The provider had clear policies and procedures in place around equality, diversity, inclusion and human rights. There was a staff handbook and a range of policies detailing how staff with protected characteristics was to be supported and protected from discrimination.

Staff were regularly involved in staff meetings and told us they had opportunities to discuss their ideas, opinions and contribute to the governance of the service. The managers had good understanding of their responsibilities and could clearly explain how their maintained oversight of people’s care and quality and safety of the service.

There were good governance systems in place and management used them effectively. The coordination of audits, checks and how the findings were shared and discussed with staff had significantly improved since the last inspection. However, we identified some improvement needs which did not affect people’s safety. For example, some behavioural incidents were not appropriately recorded by staff and reported externally although we could see evidence of action being taken to protect people. The audits did not always identify when people’s fluid records were not meeting set targets, although people received support to drink enough, and any significant concerns were discussed in clinical meetings. We fed this back to the registered manager who addressed those areas immediately after the site visit. An audit of fluid intake and behavioural records was undertaken, and staff checked if all appropriate actions were completed. The management team carried out a range of audits and checks such as care plans audits, mealtime audits, catering audit, infection prevention and control or medicines audits. They attended meetings where people’s risks and needs, as well as actions taken by staff were discussed and agreed. Staff fed back daily about any changes, support needs or issues via ‘flash meetings’ which were recorded and monitored. The provider supported the management team by completing quality assurances visits and audits around fundamental standards of quality and safety.

People and their relatives told us they could access different services as and when needed. Relatives felt included and treated as partners in people’s care. One relative said, “There are meetings to go to. They are useful and they do follow things up. Their communication is good. I can’t think of any improvements. I think it is alright.”

Staff worked well with partners. Clinical staff explained how they worked with healthcare and social care services in the local area to address people’s changing needs. The activity staff gave us multiple examples of how local community groups, neighbours and people’s families were encouraged to get involved and work with the home.

Professionals working with the home provided positive feedback to the registered manager. One of them wrote to the registered manager, “I have said it several times to your team as well as my colleagues, the home was excellent in corresponding with myself in regard to appointments, attendance. The nursing staff was always very helpful and very friendly when I have spoken to them via a phone all. I can only sing the staff's praises; they were all brilliant. Please keep up the good work!”

The home worked well with a range of partners and had established new links or improved existing relationships with the local services and the local community since the last inspection. Staff worked with the local GP and pharmacy, NHS digitising social care fund, local hospital and integrated care system care home support team, local churches, primary school, scouts club, neighbours, bus service, Surrey County Council. The registered manager was linking with the Surrey Care Association which is a not-for-profit membership organisation for adult social care providers in the area.

Staff told us lots had changed since the last inspection and a range of improvements were made to the service. One staff member said, “Things have changed a lot in the last year. [The registered manager] has made it better, mainly (improved staffing). With residents we know what they want, even the kitchen know how they like their food now. Things feel more responsible and safer. I get very good support.” Another staff member told us, “Everyone is interested in what is best for people and what they want. People know we are trying to make them happy.”

The registered manager had a good oversight of the action plans in the service and priorities for improvement. They ensured staff received ongoing support and training in their roles, team culture was improved. Changes were made to communication channels and governance systems in the service which improved overall quality of the care people received. There was significant improvement in how people were supported to remain active, independent and to do what they liked.