Kynance Residential Home

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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

Well-led – this means we looked for evidence that 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 this key question has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The provider was in breach of legal regulation in relation to the governance of the service.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders described a service that aimed to provide a homely, “home from home” environment. Providers are required to complete an annual return of information to CQC, this is called the provider Information return (PIR). The PIR for Kynance was completed in March 2026 in which the provider’s responses emphasised supporting people to make choices about their daily lives, maintain relationships, and receive care that respected their dignity and preferences.

Staff spoke positively about their roles and people and relatives also provided positive feedback about the caring nature of staff, which indicated that these values were understood across the team. However, these values were not consistently reflected in practice. Records and observations identified examples of task-led care, including the routine delivery of personal care during the night, which did not always reflect people’s individual preferences or usual routines expected within a homely environment. We also observed continence products stored in open view in people’s bedrooms, which did not support people’s dignity or reflect a personalised, home-like setting. While staff advised there were limited alternative storage options, this reduced assurance that the service’s stated values and culture were consistently embedded into day-to-day practice.

There was a clearly defined management structure in place, which included senior care staff, a head of care, a deputy manager and a registered manager. Discussions with members of the management team showed they knew people who used the service and staff well, which supported a positive and inclusive culture.

Staff, people and family members spoke positively about the management team and described them as approachable and available to provide support and guidance. External professionals also provided positive feedback, describing the management team as approachable and responsive, and confirming that staff followed clinical guidance and sought advice when required.

However, while leaders demonstrated a caring and supportive approach, this was not always reflected in consistent delivery of person-centred care across the service. This reduced assurance that leaders were always effective in embedding good practice and ensuring care was delivered in line with the provider’s values.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff felt able to raise concerns about the service and were confident these would be listened to. Staff told us they could speak openly with the management team and would be supported to raise issues where required. Staff had completed safeguarding training and were able to describe how they would raise concerns internally or externally, demonstrating an understanding of their responsibilities to protect people from harm.

People and family members also told us they felt able to raise issues or concerns with staff or the management team. This indicated that there was an open and transparent culture where concerns could be shared.

However, while systems were in place to support speaking up, there was limited evidence to demonstrate how feedback and concerns were consistently used to drive improvements across the service.

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. Leaders demonstrated an awareness of equality, diversity and inclusion and aimed to ensure staff were treated fairly and with respect. Staff told us they were positive about working at the service and felt they were treated respectfully by the management team.

Staff had undertaken training relevant to their roles, including equality and diversity training, which supported their understanding of inclusive practice. Staff did not raise any concerns about discrimination or unfair treatment, which indicated that an inclusive culture was promoted within the service.

Governance systems had not consistently identified or addressed risks relating to care delivery, including whether care was delivered in line with people’s individual preferences and the service’s aim of providing a homely, “home from home” environment. Systems and processes were in place to monitor the quality and safety of the service, these were not always effective in identifying and addressing risks to people.

Audits and monitoring arrangements had not identified areas of concern identified during the inspection, including task-led care practices, aspects of mealtime support, and environmental issues impacting on people’s dignity, as detailed within this report. This reduced assurance that care delivery was consistently reviewed and provided in line with people’s preferences, and that leaders maintained consistent oversight of care practices across all aspects of service delivery.

We identified an instance where a statutory notification had not been submitted as required. While this related to a single incident, it demonstrated that systems in place to identify and escalate notifiable events were not consistently effective. Some documentation required in relation to staff recruitment was not maintained in line with regulatory requirements, which further reduced assurance regarding the effectiveness of governance oversight. While staff feedback was positive, there was limited evidence to demonstrate how staff wellbeing was formally monitored or supported as part of a structured governance approach.

These findings demonstrated that governance systems were not sufficiently robust to identify, assess and mitigate risks to people’s health, safety and wellbeing in a timely way.

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 provider understood the importance of working in partnership with others to support people’s care and treatment. There was evidence of effective working with external health and social care professionals, including contacting them appropriately when people’s needs changed and following their guidance in practice.

The management team demonstrated an open and positive approach to partnership working and described how they would seek support from other services when required. External professionals also spoke positively about their working relationships with the service and confirmed that staff communicated effectively and sought advice where needed.

These approaches supported joined-up care and positive outcomes for people.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. The management team demonstrated a commitment to continuous learning and improvement across the organisation. Systems were in place to review incidents and there were examples of learning being identified and acted upon, including changes to equipment and reminders issued to staff to support improvements in practice.

The management team were open to feedback provided during the inspection and took action to address immediate concerns raised during the site visit. They also described how they had reviewed reports from other local services to identify areas for improvement and learning.

However, learning was not always consistently embedded into day-to-day practice. Audit and oversight systems had not identified or acted on all areas of concern identified during the inspection, including person-centred care practices and aspects of care delivery.

This reduced assurance that the provider had a fully effective and proactive approach to continuous learning and improvement across the service.