Kirk 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

At this assessment we did not assess all quality statements within this key question. We found 1 breach in regulation which related to the governance of the service. The provider’s audits failed to identify the concerns we found during the assessment in relation to the environment, medicines and infection, prevention and control. Concerns that had been found were not always actioned in a timely manner with some concerns being found again in later audits. The management team did not always promote positive cultures to ensure, where possible, immediate steps were taken to identify and reduce restrictive practices.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

When speaking with staff and the registered manager it was not evident anyone was aware of the provider’s shared vision and values although staff shared their own. The registered manager told us that communication was key for everything. That they led by example when they were in the home and made sure staff could speak to them by ensuring they were available. The registered manager stated they treated people as individuals and respected them to make choices. They explained that they concentrated on mentoring to make sure everyone was on the same page. A staff member told us the key values were ensuring people were safe and had a better way of life. They told us people had their own environments and they supported them to be as independent as they could. They explained that safety was the most important thing along with independence and happiness.

The management team did not always promote positive cultures to ensure, where possible, steps were taken to identify and reduce restrictive practices. There was evidence in care plans that some people were subject to blanket restrictions and rigid protocols that weren’t consistently and regularly reviewed to ensure they remained appropriate and justified. There was a clear divide between staff who supported people they classed as more high risk to others. Staff told us restrictive practices were used as there was a risk to life, another staff member told us they couldn’t support some people as it made them anxious. Although the registered manager told us they were working hard to integrate people more into the home, the locked environments and strict protocols supported the concerns staff had, with minimal information in risk assessments why such restrictions were needed.

The registered manager told us alongside their manager’s role they also supported other managers. They explained there were different manager’s meetings where they focused on particular tasks. The registered manager stated they were approachable, visible in the home with their ears to the ground to ensure they knew what was going on. Staff we spoke with told us they felt supported by the provider as they had the wellbeing teams who were present in the home. A staff member told us assistant managers were helpful and worked well in the teams to stop any concerns escalating. However, we received a significant number of anonymous concerns in relation to staff not feeling valued, allegations of discrimination, staff being scared to speak up to leaders or make suggestions as they felt either unheard or were fearful of discrimination. While we did not find direct evidence of these allegations, comments from staff in staff exit interviews and the concerns found by inspectors onsite which had not been identified or addressed by the registered manager, meant we were unable to confirm the provider fostered capable, compassionate and inclusive leaders.

There were regular staff meetings, however we could see from records the registered manager was not always present at these to help drive good practice and motivate the staff team. Whilst the registered manager would be informed of outcomes, this was a lost opportunity to have good oversight and support staff to speak up. The registered manager told us they were aware of culture issues such as sharing ‘horror stories’ that were no longer relevant and were taking steps to address these with staff through regular staff and individual meetings.

Staff we spoke with told us they felt confident to raise any issues with the registered manager and felt these would be addressed. Staff told us they knew how to recognise abuse and the procedures they could follow to report it. The registered manager told us they had put measures in place to encourage staff to raise concerns internally like having discussions in staff meetings and ensuring staff were aware of the provider’s whistleblowing policy. They told us there was a ‘raise it’ feature on their computer system where staff could write their concerns if they felt more comfortable doing it that way.

Despite staff feedback, CQC had received numerous anonymous concerns about the service where staff had not felt they could raise these directly with the provider. We found appropriate actions from concerns made through ‘raise its’ were not always taken. For example, a concern raised about staff allegedly using excessive force on a person had not been notified to the CQC. Providers must ensure notifications have been sent to the CQC for all incidents that affect the health, safety and welfare of people who use services as soon as possible after the event. It was not evident from the documents shared with us how this incident was investigated to conclude that abuse had not occurred.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The registered manager told us they had meetings twice a week to discuss the forms that have been created by staff including incident and accident forms. There were other planned meetings to review people’s individual needs and make plans for the week. The registered manager explained that other departments were involved with these meetings who collated information from their electronic system to review. The responsibilities and oversight for audits was mostly delegated to staff based remotely and onsite. It was unclear whether the registered manager had oversight of these audits and were aware of the findings to ensure actions had been completed. Since the assessment feedback from inspectors, the provider has recognised improvements were needed in their IT systems and processes. They told us they have taken action to review and update these to ensure better oversight. These actions included retraining staff and adding new prompts to audits. However, we do not have confidence the concerns would have been identified and this action would have been taken without CQC feedback.

The provider’s audits failed to identify the concerns we found during the assessment in relation to the environment, medicines and infection, prevention and control. It was not clear how much oversight the registered manager had due to some audits that were completed by delegated staff who scored areas highly even though there had been issues for a while. For example, the freezer was so compacted with ice you could not get the food out. The registered manager role was supported by several separate teams who were not always located in the service but worked remotely. It was not clear who was accountable for what, which meant issues had been missed. There had been concerns raised by relatives visiting the home, with a relative stating in a provider survey, “There seems to be blurred lines of responsibility with the result that some things don’t get done. We need proof that standards are being constantly and consistently monitored and maintained.” Further feedback from the relative stated, “[The provider] is very good at promoting its digital recording system but I would like to be shown in practical terms how that has specifically helped [family member].” Following our assessment the provider was planning to update their audit systems to reduce the risk of managers failing to conduct effective walkarounds and honest and effective audits. Lessons were not always learnt following incidents. We would expect providers to take immediate steps to identify and reduce restrictive practices in their services, where possible. There must be robust systems and processes to help understand the events that led up to any incidents where restrictive practice was used, report on them, learn from them, and actively work to reduce them in future. We could not be assured systems were in place to effectively monitor people’s emotional and psychological wellbeing when they were subjected to ongoing restrictive practices such as locked doors.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.