Kalm Living

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 inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to good governance.

This service scored 36 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

The provider had failed to model and monitor a positive and empowering culture where people were encouraged to develop skills and live their lives like any other citizen. Although Kalm Living was a supported living setting the culture was more reflective of a care home.

Care practices were not delivered in line with statutory and best practice guidance laid out in the Reach Standards, The Real Tenancy Test and Right Support, Right Care, Right Culture. The Reach Standards is a best practice framework for supported living services. Right Support, Right Care, Right Cultureis the statutory guidance from the Care Quality Commission(CQC) that sets out how it regulates services for autistic people and people with a learning disability. For example, people’s rights and autonomy were restricted unnecessarily.

Staff were not applying The Real Tenancy Test, which is a tool designed to assess whether individuals in supported living arrangements have genuine tenancy rights. For example, staff were holding meetings in people’s homes to which they were not invited.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

The provider did not demonstrate the experience, capacity, capability and integrity to ensure people were supported in line with both statutory and best practice guidance placing people at risk of inappropriate care and support. The registered manager had limited understanding of current best practice and was unaware of the statutory guidance Right Support, Right Care, Right Culture.

The provider did not have effective systems to ensure all staff had the skills necessary to meet people’s needs and a closed culture had developed in some settings where staff prioritised their own comfort over people’s needs and preferences. This meant people were exposed to significant risk and their freedoms unnecessarily restricted.

The provider did not have effective systems to ensure the registered manager and staff team were kept up to date on current best practice.

People did not always feel they could speak up and that their voice would be heard.

The provider’s whistleblowing policy was not up to date and did not reflect current good practice guidance.

However, the provider did value and listen to the views of staff. Staff were given opportunities to provide feedback about the service and felt their opinion was valued.

The provider 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.

We found formalised and minuted staff meetings had not taken place since 2021. This posed a risk of the provider being unable to demonstrate how they valued diversity in their workforce.

Despite this, staff told us they worked well as a team and were kept up to date with things affecting the overall service via ongoing discussions and via electronic systems.

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.

The provider had failed to establish and operate effective systems and processes to assess, monitor and improve the quality and safety of the service. Safeguarding risks were not being mitigated, and governance systems had not identified areas requiring improvement.

Systems and processes to monitor and check the quality of care were not established and were not operating effectively to ensure compliance with the regulations. Staff and managers did not understand the requirements of the Mental Capacity Act 2005. The service had failed to recognise that people’s rights and freedoms were unnecessarily restricted.

The provider did not operate in line with statutory and best practice guidance which placed people at risk of their fundamental human rights not being met.

The provider’s systems and processes failed to ensure services users were protected from the risk of financial abuse, placing them at risk of financial exploitation. There was a lack of oversight and investigation into incidents that occurred. This meant lessons were not learned and good practice was not shared.

The provider had failed to operate quality assurance systems and provider level auditing to identify important risks outlined above. This did not evidence a proactive approach to risk management and mitigation and placed people at risk.

Policies and procedures were not effective, current, in date nor reviewed annually to support best practice within the service.

Governance systems had not identified the issues found during our assessment and the impact they had on people receiving care and support from the service.

We requested evidence from the provider to be submitted by 17 December 2025. There were delays in receiving this evidence and not all evidence requested was received.

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.

Staff and leaders were open and transparent. However, they had not always collaborated well with all relevant external stakeholders and agencies. For example, managers had not appropriately escalated safety concerns and other issues found during our assessment of the service.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

Due to the lack of oversight by the registered manager and provider, there was a risk of missed opportunities to learn from events impacting on people receiving safe care and support. The service was not following current best practice, and the provider had not ensured people were supported in the least restrictive way possible. This impacted on people’s ability to lead rich and fulfilled lives.