King Street - Care Home Physical Disabilities

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• 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

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 inspection we rated this key question good. At this inspection the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care. The service was in breach of legal regulation in relation to good governance at the service.

This service scored 32 (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 did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

Following a recent review by commissioning authorities and other stakeholders the provider re-organised management oversight. However, these organisational changes significantly impacted staff morale, leading to uncertainty and disengagement across teams. Multiple changes in leadership over a short period contributed to a lack of continuity and clarity in strategic vision. Staff reported feeling unsupported and disconnected from the service’s goals, with inconsistent communication and limited opportunities to contribute to decision-making. Comments included: “There have been a lot of changes recently, and we are not sure where we are with things at all. A lot of us are worried about the future of our employment” and “The staff team seem to be doing their own thing because the changes are affecting them. Staff are worried about losing their jobs”.

These factors hindered the development of a cohesive culture and affected the overall effectiveness of leadership at all levels.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

Recent repeated changes in leadership caused significant confusion among staff teams, particularly around roles and responsibilities. Although the provider had made changes in response to stakeholder feedback, communication with staff was not consistent. This undermined the service’s ability to maintain a clear and consistent direction. There was a lack of effective clinical leadership support, which meant that leaders did not have sufficient capabilities or experience to ensure oversight of the risks presented by people using the service. As a result, risks were not consistently identified, assessed, or mitigated. Staff were not provided with appropriate governance systems or leadership guidance to manage these risks safely. This failure exposed people to avoidable harm and compromised the overall safety and quality of care.

Following the inspection the provider completed a review of the management structure and brought in a clinical lead to support the development and provide capable oversight of the service, alongside interim care managers.

People did not always feel they could speak up and that their voice would be heard.

While staff understood the provider’s whistleblowing policy and felt they could raise concerns if needed, some staff described a culture of mistrust between teams. We were told that teams were sometimes working against each other, with individuals holding onto concerns or reporting issues in a way that appeared intended to get colleagues into trouble. One staff member told us, “At the current time the staff appear to be going against one another, and they are not working as a team. It’s like everyone is trying to get each other into trouble. There has been different management, and most staff feel let down by them. This contributes to staff not raising things with the managers”. This undermined the principles of openness and transparency and created barriers to effective communication and collaboration. Leaders had not done enough to foster a psychologically safe environment where concerns could be raised constructively and without fear of reprisal.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Although policies were in place to support inclusive practice, they were not consistently understood or embedded in daily operations. Staff reported limited opportunities for training or open discussion around equity, diversity and inclusion, and leadership did not demonstrate a clear strategy to address inequalities or support underrepresented groups. In addition, there was a heavy reliance on agency staff, which contributed to a lack of cohesion among teams. This fragmentation affected communication, consistency of care, and the ability to foster an inclusive and supportive working environment. As a result, staff did not always feel valued or empowered, and people using the service were at risk of receiving care that did not fully reflect their diverse needs.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Governance, management and sustainability within the service were inadequate. There were significant lapses in oversight and accountability. Recent organisational changes and changes in leadership had not resolved this. These disruptions weakened the provider’s ability to maintain consistent governance across the service. Interim managers had implemented auditing procedures, including medicine management audits, to improve oversight. However, managers completing these audits failed to identify the concerns that were later found during our inspection. We also reviewed auditing systems intended to ensure effective oversight of accidents, incidents and near misses. However, the relevant documentation had not been completed since March 2025, indicating a breakdown in routine monitoring and risk management. These failures highlighted serious weaknesses in the provider’s internal quality assurance processes. A lack of robust systems and governance meant risks were not reliably identified, monitored or mitigated. Strategic planning to ensure the long-term sustainability of the service was limited, and leaders failed to maintain clear lines of responsibility. As a result, people using the service were placed at risk of physical and emotional harm due to ongoing failures in leadership and oversight.

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement.

The provider failed to establish effective partnerships with external stakeholders and community organisations, missing critical opportunities to work collaboratively to mitigate risks and improve the quality of care. Despite concerns being raised by partners in June 2025, about the safety and wellbeing of people using the service, leaders did not take sufficient timely or appropriate action to address these issues. At the time of the inspection there were ongoing concerns shared with us by stakeholders. Some developments had been identified by the management team who engaged in joint working with external teams to support the process. However, these had not been embedded in practice at the time of the inspection.

This lack of responsiveness undermined trust and contributed to unsafe care delivery. The absence of coordinated working and shared accountability meant that people’s needs were not consistently met in a safe or effective manner.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

Although the provider carried out monthly audits in response to concerns raised by partner organisations, these were not used effectively to deliver meaningful change. We reviewed internal improvement audits from July, August and September 2025, which identified several areas requiring immediate action or improvement. While some processes had been amended, for example, care records were being updated within the electronic care planning system and interim management arrangements were in place, there was little evidence that these changes led to improved outcomes. Despite the leadership team identifying risks, the provider failed to take timely or effective action to address them. This meant that known issues persisted, and people remained exposed to avoidable harm. The lack of sustained improvement and failure to act on audit findings compromised the safety and quality of care delivered.