Kirby Care Ltd

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 governance at the service.

This service scored 54 (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.

Some improvements were needed to strengthen the provider's shared direction and the systems used to support this. Systems and processes were not always applied consistently, which limited effective oversight and risk management and meant leaders were not always aware of issues affecting the quality and safety of care.

Despite these concerns, staff spoke positively about the culture of the service and described a supportive and collaborative working environment. One staff member told us, “Everyone gets on so well,” and said they had not experienced conflict within the staff team. Another staff member spoke positively about their role and the support they received and told us, “It’s a family and supportive, everyone is there to help, a really good team,” and “I feel quite proud working for Kirby Care.”

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.

Leaders were open and transparent in their approach and were visible within the service. However, leadership arrangements did not always provide effective oversight of care delivery. The provider had not consistently identified their own learning and development needs, and there were gaps in governance processes which meant some concerns had not been recognised or addressed through internal oversight.

Staff spoke positively about the support they received from leaders. One staff member told us, “If you are worried about anything they reassure you and help you as much as they can.”

The registered manager told us they regularly carried out care calls to people using the service. Staff we spoke with confirmed this took place. Whilst leaders demonstrated commitment to supporting people and staff, further improvements were needed to strengthen oversight and ensure learning and development needs were identified and addressed proactively.

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

Staff told us they felt able to raise concerns and were confident they would be listened to. Staff understood the processes for escalating concerns both within the service and to external agencies where appropriate. One staff member told us they would raise any concerns with the management team and said if they remained worried, they knew they could contact external organisations, including the Care Quality Commission (CQC) or the police.

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.

Staff told us they felt valued and treated fairly by leaders and colleagues. They described a supportive working environment and said leaders were considerate of their individual circumstances and wellbeing. One staff member shared their experience of caring for a family member and told us, “They check in on me,” referring to both the registered manager and senior staff, adding colleagues had also provided support during a difficult time.

The registered manager told us staff's individual circumstances, including caring responsibilities, were considered when planning work schedules and allocating hours. Staff we spoke with confirmed their preferred working patterns and personal commitments were taken into account.

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.

Governance systems and processes were not effective in providing consistent oversight, monitoring and improvement of the service. At the time of the inspection, the provider had not implemented regular auditing or quality assurance processes. The provider told us audits only commenced after they received notification of the inspection on 18 August 2026. Although some audits had subsequently been introduced, these were not embedded and had not identified the concerns found during the inspection.

Leaders did not have effective oversight of key areas of the service, including medicines management, staff training and competency, care planning, risk management, accident and incident oversight, and the application of the Mental Capacity Act 2005. This meant leaders could not be assured people were consistently receiving safe and appropriate care, and several concerns identified during the inspection had not been recognised through the provider's own governance systems.

Care records had not always been updated when people's needs changed, and protected characteristics were not consistently reflected within care plans. This meant records did not always provide a complete picture of people's current needs and preferences. The provider assured us these issues would be reviewed.

Systems for monitoring care delivery required further development. Call times were not routinely audited, and staff did not always consistently record arrival and departure times. However, people and their relatives were generally satisfied with visit times. One person raised concerns about call times, which the registered manager told us they were aware of and looking into.

The provider responded positively to feedback and began implementing improvements during the inspection. However, governance arrangements were not sufficiently established or effective to identify risks, drive improvement or provide assurance regarding the quality and safety of the service.

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.

Opportunities to engage with wider networks and forums to share learning and develop best practice were limited. This reduced opportunities to learn from others and use external good practice to improve outcomes for people.

Despite this, the provider worked with health and social care professionals to help meet people's needs. People we spoke with confirmed they were supported to access other services when required.

The provider also supported people to remain connected to their local community. The registered manager told us, "The coffee shop on the corner knows us all well. We take people for cake and coffee. It's a small village and everyone knows each other."

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 acknowledged an improvement action plan had only been implemented after the inspection was announced. Prior to this, leaders told us there was no formal improvement plan in place to identify, monitor and drive service improvements. During the inspection, feedback was shared regarding the concerns identified, including the need to strengthen governance arrangements and introduce additional quality assurance processes. The provider assured us they would review these areas and take action to address the concerns. However, some of the required auditing and quality assurance processes had not yet been introduced, and those that had recently been implemented were not yet fully embedded or tested. This meant leaders could not demonstrate that improvements were being identified and sustained through effective oversight, learning and continuous service development.