Kirby Care Ltd

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to people’s safe care and treatment and the ways people’s medicines were managed safely.

This service scored 53 (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 have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

We found the provider did not have effective processes for reviewing incidents and identifying learning to improve the safety of care provided. Prior to the inspection, the provider told us they had not been auditing falls, accidents and incidents. They subsequently completed a retrospective audit dated 18 August 2026 covering the period January to July 2026. However, this audit recorded only 1 medicine related incident and did not identify falls or seizure related incidents that staff told us had occurred. We found evidence 2 people had experienced falls which had not been captured within the provider's oversight systems.

Whilst staff were able to describe the actions they had taken at the time of incidents, there was no evidence incidents had been routinely analysed to identify trends, underlying causes or opportunities for learning. Care plans and risk assessments had not always been updated following incidents to reflect people's changing needs and risks. Although people and their relatives did not raise concerns about how incidents were managed, the provider could not demonstrate that incidents were consistently reviewed and used to inform learning, improve practice or reduce the risk of similar incidents occurring again. This meant the provider could not demonstrate a learning culture to improve the safety and quality of care people received.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

The provider completed assessments before care started. People, relatives and staff confirmed care plans were available to guide care delivery.

However, assessment and care records were not always accurate or reflective of the support people required. For example, some assessments recorded staff were to administer medicines, while the provider told us staff only prompted people to take their medicines. This showed inconsistencies in how people's support needs were recorded from the outset.

Although the provider described working with families and healthcare professionals, records were not always robust, accurate or up to date. Concerns identified in relation to medicines records and oversight meant information did not always reflect the care being provided, increasing the risk of inconsistent care. These concerns are reported in more detail under the Medicines Optimisation quality statement.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. The provider did not always share concerns quickly and appropriately.

We found some gaps in the provider's oversight of incidents and safeguarding concerns. Through discussions with people and their relatives, we became aware of incidents, including an unstageable pressure ulcer and a hospital admission, which had not been recorded through the provider's systems or notified to the appropriate authority for independent review. This meant the provider could not always demonstrate incidents and potential safeguarding concerns were consistently identified, recorded and reviewed. As a result, opportunities to identify trends, share learning and ensure appropriate action had been taken may have been missed.

Despite this, people and their relatives told us they felt safe receiving care. Staff demonstrated an understanding of safeguarding and knew how to report concerns. Records showed staff had completed safeguarding training. At the time of the inspection, no people using the service were subject to a Court of Protection authorised Community Deprivation of Liberty Safeguards (DoLS) order, and the provider had not made any applications.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We found improvements were needed in how risks to people's health, safety and wellbeing were assessed, documented, monitored and reviewed. Risks were not always supported by appropriate risk assessments or clear guidance for staff. For example, some people with known risks relating to epilepsy and falls did not have corresponding risk assessments in place. This meant staff did not always have access to clear and consistent information about identified risks and how these should be managed.

People and their relatives told us they were satisfied with the support provided, including support with managing health needs and reducing risks. However, records did not always demonstrate that known risks were consistently assessed, monitored and reviewed. This meant the provider could not fully demonstrate that identified risks were managed consistently across the service.

Despite these concerns, some staff we spoke with demonstrated a good understanding of people's individual needs and were able to describe the actions they took to support people safely.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Environmental risks within people's homes were considered as part of the provider's assessment process. Initial assessments included consideration of factors which may affect the safe delivery of care, such as trip hazards, the home environment, pets and access to the property.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

We found some improvements were needed to ensure staff had the training, skills and oversight required to consistently meet people's needs. Whilst staff had completed medicines training, competency assessments had not been undertaken. Staff told us they only prompted people with their medicines; however, records evidenced some staff were administering medicines. This showed there was not always a clear understanding of the different levels of medicines support being provided.

We identified some gaps in training and competency arrangements. For example, staff had not completed training in areas relevant to people's needs, including epilepsy and dementia, and manual handling competencies had not been formally assessed. This meant the provider could not always demonstrate staff had the knowledge and skills required to support people safely and effectively.

Some improvements were also needed in the oversight of staff development. One senior member of staff was not included on the training matrix and told us they had not completed the provider's mandatory training despite undertaking quality assurance responsibilities. In addition, staff undertaking senior responsibilities had not received any additional training to support them in these roles.

Recruitment checks included obtaining Disclosure and Barring Service (DBS) checks and references. However, safe recruitment processes were not always followed. The registered manager told us prospective staff could be introduced to people using the service before a formal application had been completed. This meant the provider could not fully demonstrate applicants had been subject to appropriate scrutiny at all stages of the recruitment process.

People told us staff arrived as planned. However, we have reported on systems to ensure care times are consistent, enough staff attended to meet people’s assessed needs and visits were delivered for the planned duration.

Staff records showed staff received regular supervision, and staff told us they felt supported by managers and were able to seek advice when needed.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

The provider’s systems for the safe management of medicines were ineffective. The provider told us they did not routinely monitor medicines management and had not completed medicines audits. This meant they lacked oversight of medicines practices and could not demonstrate people consistently received their medicines safely and as prescribed.

We identified concerns regarding the provider’s understanding of the level of medicines support being provided. Although staff had completed medicines training, records and discussions with staff confirmed medicines were being administered in practice, the registered manager was unaware staff were administering medicines. They did not demonstrate a clear understanding of medicines administration responsibilities. This meant the provider could not be assured medicines support was being delivered in line with people’s assessed needs or the provider’s policies.

Arrangements for managing medicines were not robust. Staff were unable to consistently explain whether some medicines, including paracetamol, were prescribed routinely or on an ‘as required’ (PRN) basis. We also identified a record showing a medicine had been administered; however, there was no completed Medication Administration Record (MAR) available to verify what medicine had been given. This increased the risk of harm to people because they could take too many medicines, not leave enough time between doses or not have the information for professionals in an emergency situation. In addition, there was no written PRN guidance to support staff decision-making. This meant the provider could not demonstrate PRN medicines were administered safely and consistently.

Records relating to topical medicines and other prescribed treatments were not always accurate or complete. There was no clear guidance detailing which creams people had been prescribed, where they should be applied or when they should be administered. Records relating to eye drops did not always reflect the medicines prescribed or administered. Staff also told us some people received medicines transferred into dosette boxes by family members rather than through pharmacy dispensing arrangements. This meant the provider could not demonstrate people were consistently receiving medicines as intended.

We also found one person’s prescribed pain relief patch was not always rotated in line with prescribing guidance. Records showed staff had not consistently alternated the application site. This meant the provider could not demonstrate medicines were always administered in line with prescribed instructions.

Following the inspection, the registered manager told us immediate action had been taken and provided an action plan. However, the concerns identified had not been recognised through the provider’s own governance and monitoring systems.