Kirkstall 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

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 remained good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

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.

The provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The service had a clear and shared purpose, and the management team promoted a culture focused on people’s wellbeing, safety and independence.

People consistently told us they felt cared for. One person told us, “It is well run”, while another person remarked that staff were “kind and caring”. Staff interacted warmly with people, offering reassurance and encouragement during care and daily activities.

Leaders promoted open discussion and morale was generally positive. Team meetings and daily huddles ensured all departments shared updates and maintained a consistent approach to care.

The registered manager had established a culture where people were treated as individuals, and this was reflected in respectful interactions seen throughout the inspection.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders were visible, knowledgeable and committed to improving the quality of care. Staff described the registered manager as supportive and responsive. A person told us, “The manager told me I could always go to her if I have any issues”. Relatives also spoke highly of leadership: “[Name of registered manager] is unbelievable. Nothing is ever too much for her”.

Staff reported feeling supported in their roles, and we observed respectful and compassionate interactions between leaders and people living at the service.

The registered manager demonstrated a strong understanding of people’s needs and regularly led daily huddles to ensure oversight.

Leaders acted promptly on feedback, including updating care plans, tightening medication processes and addressing gaps in documentation.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff told us they felt able to raise concerns and the management team listened. The safeguarding and whistleblowing processes were understood. One staff member told us, “We report any issues to management."

Relatives also reported feeling heard, with one stating, “I can just ring [name of registered manager] and raise concerns with her and follow up with an email”.

Feedback from external professionals confirmed the provider was responsive and open to challenge.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The service promoted an inclusive and respectful working environment. Staff told us leaders supported their individual needs, with a staff member explaining how the registered manager adjusted rotas to accommodate personal circumstances.

Policies covering equality, inclusion and reasonable adjustments were in place and staff were aware of them. There was no evidence of discriminatory practice, and leaders promoted fairness in recruitment, supervision and performance management.

Governance systems were in place but did not consistently identify or address all risks. While audits were completed regularly, several did not detect issues that were found during this assessment. For example, medication audits had not identified gaps in recording for thickener use, crushed medicines or creams, despite these omissions appearing in care records and daily notes. Relatives reported delays in communication about medical events.

The management team were responsive to concerns highlighted and acted promptly to address them, implementing new recording processes and staff guidance. However, oversight needed strengthening to ensure sustained compliance.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The service worked well with health and social care partners. External professionals described leadership as responsive and collaborative. One told us, “Staff have always been receptive and met deadlines”. The provider regularly involved district nurses, occupational therapists, GPs and social workers, and records showed care plans were updated following professional input.

The provider had established strong community links to meet people’s needs and enhance their wellbeing. This included school partnerships, pet therapy, aromatherapy and a local community centre providing activities and events. People told us outings and community visits helped maintain skills and independence.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The service demonstrated a commitment to continuous improvement. When issues were identified, such as inaccurate medication records or missing risk information, the management team acted immediately.” Staff described leaders as “responsive” and one told us, “If something needs doing it is acted on straight away”.

Records showed reflective practice was encouraged, and staff described learning from incidents involving falls, pressure care and behaviours that communicate distress.