Kingdom 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

There had been a lack of stable management support at the service which contributed to standards falling since the last inspection resulting breaches on regulation. The provider lacked an effective quality assurance system and sufficient oversight to monitor service quality and safety, as well as to ensure effective leadership. Mixed feedback was received from relatives regarding the care quality. It was observed that individuals were not consistently supported to have maximum choice and control over their lives. Feedback from staff, stakeholders, and relatives had not been collected to facilitate change or improvement. The care records and risk management for individuals needed enhancement, and the provider's systems were unsuccessful in identifying staff training requirements.

This service scored 43 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The management acknowledged the need for service enhancement and initiated the process to hire a permanent manager. The service provider assured us of their dedication to implementing improvements.

The provider had established a strategy encompassing the company's visions and values. However, the lack of consistent management input failed to instill these values effectively, leaving the service in need of distinct leadership and direction.

Staff reported inconsistent support from management, leading to feelings of neglect and isolation amid frequent changes in management. The area manager acknowledged that other departments had contributed to identifying focal points for improvement. Although some changes were implemented, they needed to be sustained.

The provider's systems and processes did not ensure the service collected feedback from partners to drive improvement despite this being an area of concern during our last inspection. We found the ongoing absence of feedback had not led to changes or enhancements.

Staff were aware of the whistleblowing procedure and knew how to report concerns through their internal systems. However, they lacked confidence in voicing concerns, expressing doubts about the assurance of confidentiality. Staff attended team meetings which provided an opportunity to share any updates and openly address any issues. Staff and leaders were open and transparent with us during the inspection.

The provider had established policies and procedures to direct the staff. However, during the period without a consistent manager, the staff's confidence in voicing concerns diminished, feeling that their issues were not always heard or addressed by the provider.

The employment of an interim manager who had been in post a short time had highlighted the need to improve the culture in the service in the service which had been without consistent monitoring due to shortfalls in management support. Work was underway to better support and engage the staff team in working in the context of equality diversity and inclusion.

The service had began to cultivate a closed culture from insufficient, steady management supervision. The provider acknowledged and recognised that if there was a steady manager in place, the service would have been run more effectively and that this was a necessary area for improvement. The provider appointed a cultural lead to enhance services requiring support in this domain. This lead had spent time at Kingdom House and had assessed the service and was drafting a report to tackle issues and steer service growth.

Leadership arrangements had not ensured the safety and quality of the service. At the time of our assessment, there was not a registered manager in post and there had been inconsistent management, oversight, and support of the home for approximately 1 year. This led to shortfalls in the quality and safety of care people received. We found 3 breaches of regulation. Although the provider had quality assurance processes they were not always followed. Audits were completed inconsistently and when they identified concerns, action was not always taken promptly. As detailed in the safe section of this report, we found issues relating to the safety, staffing and medicines that the provider’s audits had not picked up or addressed. The lack of governance and consistent leadership also meant staff sometimes felt unsure of their roles and responsibilities or did not have the time, skills or resources to undertake these sufficiently. Despite raising concerns using the providers quality assurance systems, these were not effectively addressed. Systems in place had not ensured records were always complete in relation to people's medicines. The leadership team had plans in place to improve their quality assurance systems.

The provider had structures in place to monitor and improve the quality of care they delivered but they were not effective and needed strengthening and embedding into practice. For example, the providers systems had not addressed staff who were not sufficiently trained and the quality audits had not identified shortfalls with risk management, records and the lack of stakeholder feedback.

People told us they were supported to maintain relationships with their loved ones. Relatives and representatives said they would like to be more involved in sharing their perspectives and opinions, particularly in being more informed about health appointments.

The management and staff team collaborated with individuals, communities, and external stakeholders, but this approach was not consistently applied. We identified a case where a person's health needs were neglected for a significant period. While no immediate harm occurred, the delay in seeking medical advice meant that professional consultation did not occur, and the individual's condition was not properly monitored. The provider responded and took action upon our notification.

The local authority shared concerns about the quality of care and safety of people using the service. Professionals working alongside the service had identified concerns and were taking action to ensure the management team were addressing them.

People's care plans and health records needed to be more detailed to ensure all their needs were identified. The quality of people's care records and risk management required improvement to enable effective information sharing between the service and healthcare professionals.

The management team informed us there were a lot of issues to address and were aware of the concerns. The management team had undergone a change and the service was currently being managed by the interim manager, area manager and team leaders. The current management team acknowledged they needed to improve outcomes for people. Staff told us there had been several managers who had stayed a while them moved on. Staff had found this unsettling and left them without clear guidance and direction.

Since the last inspection, the provider had not driven improvement in the service. The home's condition further deteriorated and has been rated requires improvements since the inspection. People were not consistently supported to exercise full choice and control over their lives, as active promotion of choice was lacking. Additionally, the standard of care records and risk management for individuals needed improvement and consistency. The provider failed to guarantee that staff received adequate training, their performance evaluated, and that robust, effective systems were in place to monitor the service and swiftly effectuate improvements. During the previous inspection, the provider was instructed to provide opportunities for relatives, staff, and stakeholders to offer feedback on their view of the service to aid in facilitating improvements. However, this has not yet been implemented.