Keys Hill Park

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

Well led– this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.
The service was in breach of the legal regulation for good governance.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.
The service did not appear to have a shared culture and direction. We found people who used the service received inconsistent support, so their outcomes were variable and not always in line with right support, right care and right culture.

Staff expressed concerns about the support they received and did not feel they had been listened to regarding the day-to-day practicalities of their role and hours worked. Following our feedback, the provider took action to make improvements including clearer front-line management and a detailed improvement plan to address our concerns.

Whilst we recognised the provider was making improvements to the service, with the recent recruitment of new staff and improved training, some staff felt changes had not been managed well and staff felt they struggled to meet the demands of their roles, and in keeping people safe. Staff also reported struggles with having enough competent staff available and told us people’s needs sometimes outweighed what they felt they could safely provide, creating unnecessary stress and at times staff injury.

The provider told us there had been number of listening events, forums and other mechanisms to support staff including a staff forum in March 2025. The concerns we found as part of our assessment mirrored the concerns raised by some staff at the staff forum which meant we were not assured timely actions had been taken to support staff and help them feel valued. Relatives gave very mixed feedback about the culture of the service and staff support over time, with their main concerns being communication and consistency of staff.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation, and stress appeared to be a significant factor in the well-being of staff, which impacted on the quality of care they could deliver.

There was a lack of focus on how leaders could identify examples of poor culture which impacted on the quality of people’s care and had a detrimental impact on staff. Whilst we had confidence in the area manager, they had only been at the service a short while and were on a temporary secondment. Not all permanent staff spoken with were familiar with the area manager and told us they relied on the deputy managers. The registered manager was not present during this assessment, and an acting manager familiar with the service had been supporting staff. A senior team was in place; however, several team leader positions were vacant. This meant there were inconsistencies and a lack of robust oversight by all leaders to ensure their organisational vision was delivered effectively.

Whilst we were assured that the provider was being responsive to our concerns, we continued to be concerned about the timing and roll out of the electronic care record system. The provider was using a high number of agency staff who did not have access to the electronic care records. This risk had not been recognised or addressed by leaders, prior to our assessment.

The failure to assess and mitigate risks from new people moving into the service had placed stress on the staff team. Whilst there were experienced staff available, and staff were to be commended for their hard work and commitment; risks had not been safely managed by leaders.

This was fed back to the provider to ensure that they could address it.

People who used the service felt they could speak up and that their voice would be heard, but challenges to poor practice were not always acted upon. Staff however expressed concerns about giving feedback.

There were systems and processes in place to ensure people using the service and staff could speak up and would be heard. Individual house meetings took place, rather than whole service meetings and the format was quite different for each house. We saw minutes that showed where people had not wanted to attend or contribute, but we were not sure if the reasons for this had been explored.

Leaders did not always ensure staff could feel able to speak up or be listened to. Whilst staff were happy to speak with us and did so openly, some staff were clear they did not want to be identified and did not feel able to raise concerns with management. We shared the concern of staff feeling unsupported and the risks of developing a closed culture with the area manager, so they could consider how to make improvements.

Staff felt poor practices that had been identified were addressed. However, people who used the service told us some staff were rude to them and not engaging with them. Staff confirmed they were aware of these concerns, but we were not assured they had been recorded, escalated and dealt with appropriately, including being fed back to the provider. Relatives also told us about concerns they had. One relative told us they had concerns about the lack of confidence in some staff. We have sought assurances from the provider regarding these concerns.

The service mostly valued diversity in their workforce and were working towards an inclusive and fair culture by improving equality and equity for people who worked for them. However, some staff did not feel valued.

There was diversity within the workplace and staff were supported in their development through mandatory training and role specific training. Training compliance had improved but there were low levels of compliance in some areas of training and development. In particular, agency staff did not have the key skills required to work safely with people who could have distress behaviours, a learning disability and epilepsy.

Statistical information showed a low up take of higher qualifications in care which might enable staff to feel more confident in their role and seek promotions. We discussed creating champion roles with the provider, which whilst not mandatory, might support staff in developing their role and confidence in areas of expertise they were interested in.

Staff told us they did not always feel they were supported with learning and reflection when incidents occurred. We expressed concern that not all staff had completed the mandatory training in learning disability awareness. The provider assured us that they would be rolling out The Oliver McGowan training to all staff which is the governments preferred and recommended training for care staff.

Systems and processes were in place to support equitable staff recruitment processes. During this assessment, some staff expressed some concerns about racism, which we fed back to the provider to explore further and address accordingly.

Whilst the service had clear lines of responsibilities, roles, systems of accountability and governance this was not effective in ensuring good outcomes for people and ensuring effective risk management was in place.

A tiered governance system was in place with clearly defined processes, but these processes had not been fully effectual in identifying all the risks we found during out assessment: such as concerns around fire safety, epilepsy management and accessibility to records. The provider took prompt action to address our concerns, after we shared them.

At the time of our assessment there had been a significant increase in staffing hours due to new admissions to the service which was impacting on the confidence and ability of permanent staff to meet needs. The provider explained to us matching the right staff to each persons needs and the impact of having new staff requiring induction and supporting agency staff, ( some new) was a challenge for the service. Staff working across different houses meant seniour staff were required to complete both care hours and administrative hours and each house was managed differently. This resulted in a lack of consistency and stability across the service.

There was evidence of agency staff lone working with people and information about their training and skills to do so, was not sufficiently detailed. Furthermore, agency staff members induction to supporting people, some of whom had complex needs, varied and, in some cases, could not be evidenced. Agency staff often relied on other staff who were trained to give medicines or with other required skills, to come from another building to do so. This meant there could be delays in people getting timely care and support.

We had concerns about fire safety and the safe evacuation of people in the event of a fire due to the lack of some staff’s knowledge and the absence of regular fire drills across all the houses. Not all staff had access to individual fire risk assessments which would inform them of what actions they should take to safely evacuate people. There was also a lack of clarity of who would assume the role of fire marshal to ensure there was clear leadership in the event of a fire. Fire grab bags were not accessible until we requested this.

The provider had failed to ensure all staff had access to detailed and up to date care records for people. The electronic recording system had been in place for six months and had been introduced at a time of high agency staff and high vacancy rates, with ineffective contingency plans. The provider had failed to mitigate risks associated with information governance and oversight.

We found there was a poor handover process, due to the lack of time allocated and a clear record system for staff to share important information between shift changeovers. There was inconsistent recording of people’s day to day needs particularly in relation to their well-being and risk.

Leaders of the service described a feeling of’ burn out.’ This meant we were not assured there were sufficient, clear and effective governance processes in place.

The service understood their duty to collaborate and work in partnership with other agencies to try and secure the best outcomes of care for people. They shared information and learning with partners and collaborated for improvement.

Relationships and communication between the service and commissioning bodies was seen as positive with good collaboration between the service and other statutory and non-statutory agencies. The suitability of individuals’ placements and funding agreements were kept under review and multidisciplinary meeting minutes were viewed which showed evidence of collaborative working.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always consistently deliver creative equality of experience, outcome and quality of life for people.

People and their families were not routinely involved in developing and evaluating improvement and innovation initiatives. This meant improvements that could have been identified may have been missed, impacting on people’s experiences.

Leaders did not always encourage staff to speak up with ideas for improvement and innovation and actively invest time to listen and engage. Some staff mistrusted change as a result, which impacted efficacy.

We saw some examples of person-centred care but were concerned there was a lack of consistency and continuity. This impacted on people’s experiences and the experiences of their families. In addition, this was further impacted by staff trying to provide complex support to people, when they lacked confidence and support themselves.

However, the provider did have a clear leadership and development strategy, and we were assured the service could make the improvements needed with a strengthening staff team and strong leadership.

Following our assessment visits, the provider shared evidence of improvements being made, including systems and processes and strengthening the staff team. The provider assured us improvements would be made, embedded and sustained to ensure improved outcome for people.