During an assessment under our new approach
Date of Assessment: 26 November to 09 December 2025. Kirklands is a residential care home for up to 46 older people, some of whom may be living with dementia. At the time of this assessment there were 43 people living at the service.
We undertook this assessment following information of concern received about how the service managed people’s care needs, people’s falls risks, how they investigated incidents and complaints and about staffing.
We assessed the quality statements from the key questions of safe, effective, caring, responsive and well-led.
We found three breaches of the legal regulations in relation to safe care and treatment, need for consent, and good governance. The service did not always ensure safeguarding procedures in place were effective. The service did not always ensure people’s risks were recorded and some people’s risk assessments contained inconsistent information. The service did not always ensure people’s consent was gained or recorded where required. The systems in place to assess and manage the quality and safety of the service were not always effective.
The service identified and investigated concerns about safety and took action to keep people safe where required. However, lessons learned from safety incidents were not always shared and discussed with the staff team to continually embed good practice. A lack of information or inconsistent information in people’s care plans and risk assessments meant there was a risk people would not experience a smooth transition between different services. The service had safeguarding procedures in place, and concerns were investigated and acted on. However, some staff told us they did not feel confident to raise concerns or whistle blow.’ Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. However, care plans did not always include information about people’s risks. The service did not always assess or manage the risk of infection. However, the service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The service made sure there were enough qualified, skilled and experienced staff who worked together well to provide care that met people’s individual needs. The service made sure that medicines were safe and met people’s needs, capacities and preferences. However, topical preparations were not well managed, and we found occasional shortfalls in medicines record keeping.
The service did not always have effective procedures in place to ensure people's care plans included detailed and consistent information. The service did not always routinely monitor people’s care and treatment to continuously improve it. The service did not tell people about their rights around consent or respect these when delivering care and treatment. However, the service planned and delivered people’s care and treatment with them, including what was important and mattered to them. The service worked well across teams and services to support people. The service supported people to manage their health and wellbeing to maximise their independence.
The service always treated people with kindness, empathy, dignity and compassion. Staff treated colleagues from other organisations with kindness and respect. The service treated people as individuals and made sure people’s care, support and treatment met people’s needs and preferences. The service promoted people’s independence, so people knew their rights and had choice and control over their own care, treatment and wellbeing. The service listened to and understood people’s needs, views and wishes. Staff responded to people’s needs in the moment and acted to minimise any discomfort, concern or distress. The service had an employee engagement manager who visited the home to promote the wellbeing of staff. However, while some staff felt the management team supported their wellbeing, others did not feel valued or that they could speak confidentially.
The service made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs. The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity. The service made sure that people could access the care, support and treatment they needed when they needed it. Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this. However, the service did not always supply appropriate, accurate and up-to-date information in formats that were tailored to individual needs. The service did not always make it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. People were not always supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.
The service 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. Not all leaders understood the context in which the service delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. The service did not always foster a positive culture where staff felt they could speak up, and their voice would be heard. The service did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them. The service 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 service did not always focus on continuous learning, innovation and improvement across the organisation and local system. However, the service understood their duty to collaborate and work in partnership, so services worked seamlessly for people.
We have asked the provider for an action plan in response to the concerns found at this assessment.