Kite Hill Care Home

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 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 legal regulation in relation to good governance at the service and a failure to notify.

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 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.

The provider was unable to provide recent staff surveys or feedback from the staff team. The provider told us their Statement of Purpose, which outlines the type of service and how they intend to deliver care, had not been reviewed for a significant period and required updating. This limited assurance that staff feedback was sought, reviewed and used to support a shared direction, vision and purpose for the service.

We received mixed feedback from staff about the culture. Comments included; “The door is open, the management is very appropriable and will always listen”, “I feel as a care home that there is a lack of communication from management to Seniors to Carers” and “I don't feel [supervisions are] happening enough for all care staff to know what we are doing well or can improve on.”

We did not identify any concerns regarding the caring interactions between staff and people using the service. However, weaknesses in governance and oversight limited the provider’s ability to demonstrate consistency in care, and a clear, shared vision and culture, including how learning, feedback and improvements were embedded within the service.

Leaders did not always have the skills, knowledge and experience to lead effectively.

The provider did not demonstrate effective leadership and oversight to ensure regulatory requirements were consistently met. They did not consistently demonstrate their capability to identify and address risks without delay.

Management did not always demonstrate sufficient skills and knowledge of the regulatory requirements, national or best practice guidance to ensure governance arrangements were effective in identifying and addressing shortfalls.

At this inspection we identified 5 breaches of the legal regulations. The concerns identified on this inspection as detailed throughout this report had not been identified or effectively managed until highlighted by inspectors.

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

Most staff that we spoke with described the managers as having an open door policy and were approachable. People and family members as well as external professionals felt able to raise any concerns with the management team.

The providers whistleblowing policy, which encourages staff to raise concerns did contain outdated information and did not provide clear external reporting contacts, information about confidential or anonymous reporting. However, following our feedback, the provider told us the policy had been updated.

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.

We found that staff received equality and diversity training, and the provider had an appropriate equality, diversity and human rights policies in place.

The provider told us that consideration could be given for individual staff needs, although no staff required additional support at the time of our inspection.

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.

Auditing systems for identifying, capturing and managing organisational risks were ineffective. The providers audit schedule identified a significant number of key audits were recorded as 'new', meaning these had either not been completed or there was no established audit history. We identified significant shortfalls on this inspection including safe medicines management, risk management, consent, staffing and learning from incidents.

Systems and processes to review care plans and monitoring records had not identified there was a lack of comprehensive, detailed records, including care plans and risk management plans to provide staff with sufficient guidance on how to meet people’s individual needs and provide them with safe, effective and responsive care. Additionally, the concerns we found in relation to safe medicines management and mental capacity assessments had not been identified through the providers own governance arrangements.

The provider did not have effective systems to monitor Deprivation of Liberty Safeguards (DoLS) authorisations and the conditions attached to them. Although some people had authorised DoLS with specific conditions in place, management could not demonstrate how they monitored these conditions or ensured the required actions had been completed. This increased the risk that legal requirements and conditions intended to safeguard people would not be consistently met.

The provider failed to meet their regulatory requirement to inform CQC of notifiable incidents affecting people’s health, safety and welfare.

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

The service worked with external partners, including GPs, district nurses and the local authority. However, on review of a person’s care record we identified recommendations made by external partners had not been implemented.

Furthermore, the management team failed to notify the local authority of relevant required safeguarding information. This meant the provider could not demonstrate that it was consistently working with external partners to drive improvements and achieve better outcomes for people.

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.

The provider did not have an effective system or plan in place to monitor and improve the quality and safety of the service. Monitoring systems were not effective and had not identified the issues we found during the inspection.

The provider could not demonstrate effective systems for identifying patterns, themes or emerging risks across the service. This meant opportunities to drive improvements in the service and to ensure promotion of a culture of continuous learning and improvement had been missed.