Roy Kinnear House

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.
This is the first assessment for this newly registered service. This key question has been rated 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 governance at the service.

This service scored 61 (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 provider had a range of policies and procedures in place to guide staff and support consistent practice. These included policies on safeguarding, equality and diversity, infection prevention and control, and complaints handling.

On the day of the inspection, a member of the provider’s quality team carried out an internal quality audit. They stated the findings would be used to inform improvement actions and support the incoming manager in identifying learning needs and service priorities.

The provider also had an initiative in place called the equality and diversity plan, which they stated were designed to support and champion inclusive practice across the organisation. This included promoting fair access to care, supporting staff from diverse backgrounds, and embedding awareness of people’s protected characteristics into service delivery.

We saw that an easy-read version of this equality and diversity plan was available at the service, and staff were able to speak confidently about its purpose and relevance to their roles.

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. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty. At the time of the inspection, there were no registered manager in post. The provider was actively recruiting to fill this role and had appointed a clinical lead to provide day-to-day oversight, supported by the regional manager. Recruitment checks for staff were completed in line with safer recruitment practices.

Although efforts were being made to stabilise leadership and maintain oversight, we could not be assured that the current interim arrangements were effective. Audits and spot checks relating to service culture and quality of care had not been conducted regularly, and where concerns had been identified, actions were not always followed through. Some staff told us they felt overwhelmed and expressed concern about the sustainability of current leadership support. While the provider had taken steps to address these issues, including ongoing recruitment for a permanent manager, further improvement was needed to ensure leadership arrangements were embedded and effective.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. There was a whistleblowing policy in place, and a related poster was displayed on the staff noticeboard. Staff we spoke with said they felt able to raise concerns and described a culture that encouraged open dialogue. They gave examples of how team meetings provided them an opportunity to also voice their concerns. Staff told us they were confident that concerns would be listened to and handled appropriately. Leaders were open to feedback and made themselves accessible to staff. Families felt they could speak with anyone at the service if they had a concern. A professional also said they felt the provider were open to feedback and had been present in feedback meetings.
 

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 provider demonstrated a clear commitment to promoting equality, diversity, and inclusion in the workforce. Staff completed equality, diversity and inclusion (EDI) training during induction and through ongoing learning. Staff explained how this supported them to recognise and respect people’s individual backgrounds and protected characteristics.

The service had an equality and diversity plan in place, including an easy-read version available within the home. Staff were familiar with the plan and spoke positively about how it helped promote fairness and inclusion.

Policies were in place to ensure equal opportunities for all staff, including those with protected characteristics. These covered areas such as non-discrimination, anti-bullying, and the provision of reasonable adjustments for disabled staff. Leaders confirmed that recruitment processes were inclusive and followed fair practice.

The provider had set a goal to ensure the workforce were reflective of the people it supported, including people with disabilities. Staff told us they felt respected and valued in their roles and described the service culture as inclusive and supportive. Leaders promoted openness, equity, and cultural sensitivity across the service.

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.

The provider had governance systems and policies in place, including processes for quality assurance, auditing, and risk management. However, these systems were not consistently or effectively implemented. Several governance failures were identified during the assessment.

Health and safety audits had not been completed between January and April 2025. This included missed environmental safety reviews, fire drills, and maintenance inspections. These omissions were not in line with the provider’s own policies, which outlined the frequency and expectations for such checks.

Medicines management systems were not operating effectively. The most recent audit on record were from December 2024. The issues identified during that audit remained unresolved. The auditing process had not led to prompt corrective action, and there were no clear evidence of follow-up or learning from the identified issues. This fell short of the provider’s own medicines governance procedures.

Daily diary records had not been audited, and outcomes were not well recorded.

Staff supervision records were not consistently maintained, with gaps noted across several staff files and limited evidence of regular, structured supervision taking place.

Although the provider had implemented a quality framework and conducted internal audits, evidence of timely learning, action, and improvement were limited. The governance systems in place did not ensure effective oversight, accurate record keeping, or the ability to promptly address risks and shortfalls.

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 had established working relationships with external professionals, including GPs, district nurses, social workers, and community learning disability teams. Staff worked with these professionals to ensure individuals received the health input they needed in a timely manner.

People were supported to maintain meaningful connections with the local community. For example, staff helped individuals attend church services.

Staff also supported people to use their personal bus passes to access the community and local activities.

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

The provider had begun implementing an electronic care planning system intended to improve the quality of care recording, planning, and monitoring. At the time of our assessment, the system had not yet been introduced into practice. Staff told us they had been booked to attend training but had not started using the new system.

Managers said this development was expected to support more person-centred documentation and improve consistency. However, the current paper-based systems remained in use and did not provide structured or outcome-focused records. This limited the service’s ability to monitor and evaluate care effectively.

However, the provider had identified the move to electronic systems as a key improvement strategy, we found no clear evidence that learning and innovation were being embedded in practice. The current arrangements did not give us confidence that improvement was being driven or sustained across the service.