Kimwick Care Home

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 Requires Improvement. At this assessment the rating has changed to Inadequate.

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.

We identified 1 breach of the legal regulations in relation to the governance of the service. The governance systems in place were not effective in identifying areas for improvement and the provider had failed to act to maintain the service to a safe standard. We received negative feedback from commissioners and people’s relatives about the management and leadership of the service. There had been no improvement at the service since our last inspection and many areas of the service had deteriorated.

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 sought feedback from staff on the quality of the service. However, only 2 completed feedback forms were provided for this assessment. Both rated the service as overall outstanding which did not reflect the findings of this assessment. No analysis of the staff feedback had taken place.

We received positive feedback from staff about the management and culture of the service. Staff we spoke with told us there was good teamwork in the service and that all staff worked well together.

There was a lack of management and provider oversight to ensure Right Support, Right Care, Right Culture was being considered in line with the guidance. Leaders and staff failed to ensure autistic people and people with a learning disability were living an ordinary life as any other person would. There was a lack of provider oversight to ensure people were supported to grow their independence and had access to activities that were important to them. There was no evidence these areas had been audited and the concerns found with the provision of person centred during the assessment had not been identified by the provider.

Staff told us the manager and provider were supportive. However, they said that improvements required in the service had taken too long to be implemented.

Processes were not effectively implemented to help make sure the manager and other senior staff were capable in their job roles. The provider could not be confident the processes they had in place for monitoring and improving the quality of the service were used effectively. We identified multiple areas of concern during this assessment. These had not been identified by the management and leadership within the service.

There was no clear support structure in place for the manager in the service. In addition, the provider undertook no audits, they could not be assured capable, inclusive leadership was in place.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

There was no registered manager at the service. The previous registered manager had de-registered on the 21 May 2024 and the provider told us the current manager would be registering as manager for the service. At the time of the assessment no application had been submitted.

The manager and staff told us they were supported by the provider and systems were in place for the management and oversight of the service. However, during this assessment, we identified that systems of oversight were not being implemented effectively and there were multiple concerns within the service. These had not been identified or acted upon in a timely manner.

The provider had failed to ensure governance processes were effective. The systems in place had not resulted in the service being maintained to a safe and appropriate standard. Areas for improvement were not identified, and improvements were not made when required.

The provider had failed to implement a system of oversight to monitor the management of the service since the previous registered manager de-registered on 1st May 2024. Since the previous registered manager de-registered audits had not been consistently completed. Where audits had been completed it had not been identified they had not been completed accurately.

There was poor governance and a lack of ongoing monitoring of care documentation. People's care plans and risk assessments contained incomplete information about people's needs. There was a risk people would not receive appropriate care.

The system to ensure safe management of medicines was ineffective. The provider failed to identify that staff were not keeping a record of medicines brought into the home, were not completing MAR charts accurately or storing controlled drugs safely.

The provider failed to ensure people were protected from risks associated with the upkeep of the environment and equipment. The systems in place to assess, monitor and mitigate environmental, fire safety and infection control risks were not effective.

There was a lack of oversight of safeguarding and accidents and incidents.

There was no oversight of recruitment records and staff training. Recruitment records were incomplete. Mandatory training had not always been provided as required.

The provider failed to implement a system to ensure staff were effectively deployed to meet people’s needs.

Failure to maintain oversight of quality monitoring processes placed people at risk of receiving poor care.

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.

The manager and staff told us they believed people were receiving a good standard of care from the service. However, at the time of assessment, we found multiple areas of concern in the service that that had either not been identified or addressed.

Processes were not implemented effectively to enable lessons to be learned and improvements made. Audits were not effective in identifying where improvements needed to be made. There had been no improvement at the service since our last inspection (report published 25 August 2023) and many areas of the service had deteriorated. The service was still not meeting the fundamental standards we expect from care services. Although the provider had begun to address some areas of concern at the time of the assessment, we found further concerns placing people at risk which had not been identified by the provider.