Kirklands

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 good governance. The systems in place to assess and manage the quality and safety of the service were not always effective.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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.

The management team was in the process of improving the culture of the service and the staff team. However, further improvements were required to ensure all staff were treated with fairness and for them to feel able to raise issues about the service.

Senior managers were open and responsive to feedback and advice throughout the inspection. Staff demonstrated a commitment and genuine fondness for the people who they were supporting.

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. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

While some staff felt leaders were skilled and led with integrity, others felt this was not the case. One staff member told us, “The [operations manager] really gets across how residents should be treated and that this is their home. There is good communication from the top downwards.” Another member of staff told us, “There have been staff leaving recently. We were told we were not doing a good job.”

The service was experiencing changes in management. At the time of the inspection, there was no registered manager in post.

The service did not always foster a positive culture where people felt they could speak up, and their voice would be heard.

While the service had a whistleblowing policy which staff understood, staff did not always feel able to speak up about concerns without fear of detriment and were not always confident concerns would be acted upon.

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.

Whilst we saw evidence the management team supported staff to work more flexibly when needed due to personal commitments or caring duties, staff did not always feel they were treated equitably.

We discussed with the management team how the use of language around diversity could impact on their staff and the people they support.

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 management team told us consent had been previously obtained from people regarding the use of CCTV on the premises. However, governance procedures had not identified these had been misplaced. Consent had not been obtained from people who had recently come to live at the care home. Governance procedures had not identified issues where mental capacity assessments had not been carried out or with the quality of some mental capacity assessments in place.

Audits of medicines had not identified issues with how topical preparations were managed and with record keeping.

Infection prevention and control audits and environmental checks had not identified issues with PPE availability for kitchen staff and with laundry records and risk assessments.

Governance procedures had not identified issues with the quality of supervisions and team meetings and how these were recorded.

Governance procedures had not identified the lack of follow up on resident and staff survey responses

Audits of accidents and incidents had not identified learning from investigations was not always being shared with staff.

Care plans were not being audited therefore issues with information in care plans and risk assessments were not being identified. Following feedback from the inspection team, the management team put a plan in place to audit each person’s care plan.

The service understood their duty to collaborate and work in partnership, so services worked seamlessly for people.

The service was embedded in the community it served and was considered a valued partner by others in the community. One visiting professional told us, “This is a really nice home to come to, and the staff are very helpful.”

The service 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 service was engaging in a quality improvement process with the local authority and health partners. Although this had led to some improvements, support was still required to ensure the service provided consistently safe and effective care and with governance procedures.