Kirby Care Ltd

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

This service scored 58 (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 always make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them.

Improvements were needed to ensure people’s needs were fully assessed and accurately reflected in care records. We found people’s physical and mental health needs were not always comprehensively assessed, and care records had not always been reviewed or updated to reflect current needs and the care being provided. This meant the provider could not be assured care, support and treatment were consistently delivered in line with people’s assessed needs.

Despite these concerns, people and their relatives were positive about the care provided and told us they were satisfied with the support they and their family members received.

The provider did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them.

Some improvements were needed to ensure care, treatment and support were consistently delivered in line with recognised guidance and best practice. Leaders were not always able to demonstrate how evidence based approaches were used to assess, monitor and manage people's needs. For example, recognised assessment tools, such as a Waterlow assessment, used to calculate a person's risk of developing pressure ulcers, had not been considered where they may have supported the identification and monitoring of risks. We also identified concerns in relation to medicines management, where practice was not always aligned with The National Institute for Health and Care Excellence(NICE) whichprovides national guidance and advice to improve health and social care. This meant the provider could not always demonstrate care and treatment were consistently delivered in line with recognised best practice and evidence-based guidance.

We did not look at How staff, teams and services work together during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

The provider did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

We could not be assured people’s expectations about the care they received were understood by staff and managers. Systems for monitoring the effectiveness of care and support were not effective. Where people required additional monitoring, this was not always in place. For example, 1 person had an unstageable pressure ulcer which the provider had not identified through their own oversight processes. In addition, monitoring of specific aspects of care, such as the rotation of prescribed pain patches, was not consistently recorded or reviewed. This meant the provider could not be assured care remained safe, effective and responsive to people's changing needs.

However, some people's care records included outcomes centred on maintaining independence and remaining at home. People and their relatives told us the support provided helped people achieve these outcomes and promoted their ability to live independently within their own homes for as long as possible.

Following the inspection, the provider told us they would take action to strengthen their monitoring and oversight arrangements.

The provider did not always tell people about their rights around consent and did not always respect their rights when delivering care and treatment.

We found the provider could not always demonstrate that consent to care and treatment was managed in accordance with the Mental Capacity Act 2005. Records did not consistently contain information about people's capacity to make decisions, their ability to consent to care, or any support they required with decision making.

The provider told us only1 person using the service lacked mental capacity; however, a mental capacity assessment and best interest decision had not been completed for this person. Discussions with staff and family members indicated other people living with dementia or Alzheimer's disease may have required assessment of their decision-making abilities. Despite this, there was no evidence mental capacity assessments had been considered or completed. This demonstrated the provider did not have effective oversight of people's mental capacity to consent to their care and make decisions and choices.

Staff training records also identified areas for improvement. The training matrix dated August 2026 showed over 30% of staff required refresher training in the Mental Capacity Act 2005, and no staff had completed training in understanding dementia or Alzheimer's disease. Therefore, the provider could not be assured staff had the knowledge and skills required to recognise when people may need additional support with decision-making or when further assessment was required.

Despite these concerns, people and their relative we spoke with told us staff sought their agreement before providing care and support and offered them choices about how their care was delivered.