Kirby 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.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff and leaders fostered a positive, compassionate, listening culture that promoted trust and understanding between them and people using the service. The registered and area managers had instilled a positive working culture at the service. This was supported by our observations and feedback from people, relatives, staff and external professionals.

The atmosphere was homely and welcoming, and staff were consistently available to people and were polite and courteous in their approach. A person told us, “The staff treat me very well, they are kind and caring.” Whilst a second person said, “I do know the manager. I think this is a well-run home. I am very, very happy here.” A relative told us, I do know the manager and I am very happy with mum’s care.”

Staff views were sought through a quality assurance survey, whilst the survey asked staff for their views regarding the services vision and values, good communication, diversity and inclusivity, the questions and responses were specific to Kirby House and not the wider organisation.

The registered manager shared how they supported equality and diversity within the staff team, by ensuring staff felt respected, and valued regardless of their background, culture or personal circumstances. The advised this was underpinned by policies on equality and diversity, and applied in all interactions with staff, including induction, training, supervision and meetings.

People and staff were supported by capable and inclusive leaders who had the skills, knowledge, experience and credibility to lead effectively. The registered, deputy and area managers understood their roles and responsibilities, and received ongoing support from the head of care operations.

Whilst we did identify a few areas requiring further improvement, leaders were responsive to concerns when raised and remained receptive to feedback throughout the inspection process.

The head of care operations made themselves available to support the management team with the inspection. They spoke of future plans for the service and the wider organisation, and remained open and transparent about things they felt still needed to be improved.

The registered manager informed us that they completed a full induction programme, which included classroom based learning, and working alongside experienced staff which enabled them to become familiar with, and understand the needs of people at the service. The registered manager advised they received ongoing support through supervision, training and development.

The staff team spoke positively of the registered manager and the management team, who they described as being approachable, leading by example and supportive. A member of staff told us, “It is a good team, a good working environment.”

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

Staff were aware of the provider’s policies and procedures which supported them to raise any issues relating to poor practice, concerns and complaints. A member of staff told us, “I would report any concerns to the manager.” Whilst another member of staff said, “I can say what I’m not happy about to management.”

The registered manager informed us there was a clear whistleblowing policy which staff were made aware of during induction and ongoing training. They advised an open and supportive culture encouraged staff to speak up without fear of reprisal. Staff meeting minutes evidenced staff were reminded of the whistleblowing policy.

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’s policies and procedures supported equality, diversity and inclusion in the workforce.

The registered manager understood their responsibilities in line with the Equality Act 2010 and its implications for employees. The registered manager was aware of their role in upholding the principles of the Equality Act. They informed us the provider’s policy and procedure for equality, diversity and inclusion was shared with staff at induction, training and reinforced at staff meetings and supervision.

The registered manager advised where staff disclosed a disability of specific need, an assessment was carried out to identify and agree any suitable adjustments, which were reviewed for their relevance and effectiveness. A member of staff told us flexible working considered potential barriers, for example childcare.

The provider had a range of quality assurance and oversight processes in place. However, the effectiveness of these could be improved by increasing the scope of audits and increase monitoring to ensure timescales set for compliance are achieved, where improvements have been identified.

We found improvements to the environment were required, of which some had not been identified by the providers audits. For example, environmental and infection prevention audits had not identified external garden benches had peeling paint, and an item of moving and handling equipment had damage to the painted surface. Where improvements had been identified, dates set for compliance were not consistently met, and were recorded as ‘outstanding’, these in the main related to environmental improvements. Repairs to exposed plaster in 2 bedrooms and the replacement of 2 damaged bed frames were promptly addressed by the provider, which had been highlighted during the inspection process.

People’s voice, and feedback from relatives and staff was not reflected in the services overall improvement plan or audits undertaken by the senior management team, which if included would support the provider in the delivery of high quality care and good outcomes. People’s views and that of their relatives and staff were sought through meetings and surveys. The outcome of surveys were in the main positive, areas for improvement identified included an increase in opportunities for people go out, including day trips.

A managerial structure consisting of a head of operations and area managers visited the service as part of the providers monitoring and auditing systems and processes. The area manager undertook a range of audits and reviews, and developed an action plan where shortfalls and improvements were identified. Audits and reports undertaken by the registered and area manager were reviewed by the head of operations.

The registered manager informed us where improvements were identified, through auditing, incident investigations or feedback these were shared with the team. The registered manager understood their regulatory responsibilities, which included sharing information with the Care Quality Commission and external stakeholders.

The management team and staff 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 registered manager informed us the staff team worked collaboratively with partner agencies, such as healthcare professionals, local authorities and training providers by sharing information during multidisciplinary meets and care reviews, and that this approach enabled the staff team to learn from wider expertise and ensure co-ordinated support for people.

Records showed staff had contacted a range of health and social care professionals. This enabled people’s health and wellbeing needs to be assessed and continually reviewed so as people’s individual needs were met.

The providers systems and processes mostly supported continuous learning, innovation and service improvement. The management team contributed to safe, effective practice and research.

The registered manager informed us they had engaged in pilot programmes with local health authorities to explore approaches to care. For example, the service had recently been part of a study, enhancing dementia care through stimulation, which had informed changes in activity planning. However, staffing resources did continue to impact on people’s opportunities to access services and events within the community.

Investment in the digital care planning system had improved efficiency and accurate of recording people’s needs, by ensuring staff had up to date information at their fingertips.

External agencies informed us representatives from Kirby House attended provider forums organised by the local authorities, where updates and contract information was shared.