Kaplan Care

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• 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

We found that the service continues to Require Improvement in relation to the Well-led domain.

We identified one breach of the legal regulations. There was no registered manager at the service at the time of the inspection. People, their relatives and staff told us the director/provider was not always available to run the service. There was a lack of leadership support for staff to enable them to be effective. There was a poor culture in the service. Staff did not always follow the policies and procedures in place, and this had not been addressed with staff. Records of complaints, incidents and accidents and concerns about the service were not maintained. There were no systems in place to discuss and share learning from incidents and accidents. The quality of the service was not effectively monitored and assessed to identify gaps.

This service scored 43 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was lack of leadership and support for the staff. Staff told us they there were not provided the direction and leadership they needed to be effective in their roles. Staff told us when the new provider took over the service, they were not always available to provide guidance and leadership to them. They felt unsupported.

The provider failed to properly plan their strategy for the effective management and running of the service.

We found that there was lack of cooperation from staff and leaders. They did not share a common goal. Staff did not feel supported and involved in the running of the service.

These concerns had affected the effectiveness of staff in providing effective care to people using the service.

There were no systems and processes in place to promote a positive culture in the service. People and their relatives told us the new provider had not made effort to meet with them at the initial stage to introduce themselves. One relative told us, “I still haven’t met [the provider]. For a company of this size, you would think [the provider] would endeavour to meet [their] customers and introduce [themselves] properly.” Another relative said, “[The provider] did not make a good impression. [They] did not make effort to liaise with us. It was hard to get [them] on the phone. [The provider] couldn’t keep [their] good staff. [The provider] was just not there for the staff to establish [themselves]. [The provider] left the business to the staff. I have given my feedback, and [the provider] is trying to turn things around.”

The provider had recently taken over the business. At the start of the transition, the new provider had not taken the time to meet with people, their relatives and staff to build relationships and share their visions for the service. They had not consulted with people, staff and relevant partners so their views could be used in developing the service.

At the time of our visit there was no registered manager in place. The provider was responsible for the day-to-day management of the service whilst also covering care visits. We found that there was no system in place to ensure calls to the service were responded to promptly. People, relatives and staff confirmed that they often were unable to contact the service to discuss issues or raise concerns they have.

We also found that there were no systems in place to provide direction, guidance and support to staff. Team meetings were not taking place, and staff supervisions were not regular.

There was a lack of visible and effective leadership in the service. Staff told us the provider was not understanding, compassionate and approachable. There had been a hostile relationship between the existing staff and the new provider, and this had not been managed effectively. One staff member said, “There have been issues since the new management came on board. The main concern is that they don’t communicate with us. They are not always available when we need them.”

The provider explained that they had struggled to recruit a manager to support staff day-to-day whilst they planned their relocation to the area. They told us they had now relocated and were available to support staff.

The provider had failed to provide a support system and opportunity for staff to improve their morale and effectiveness.

We found that there was lack of trust between the provider and staff. The provider had not taken steps to make sure the staff team felt included and supported through the period of transition from the previous provider to the new.

At the time of our visit there was no registered manager in place. There were no formal meetings for staff to raise their concerns and discuss their ideas about the service. The provider told us they had recruited a new manager who would register with CQC and will be responsible for the day-to-day running of the service to improve the experience of people and staff.

All the staff we spoke with knew the procedure to raise their concerns internally and externally. We found staff were raising their concerns externally only, including concerns relating to people’s care. Staff told us they did not have a working relationship with the provider. There was a lack of trust between the provider and staff.

The provider had a whistle blowing policy which provided details on how to raise concerns within and outside the organisation. We found staff did not follow their procedures and the provider had no systems to address this issue with staff to improve this.

Staff confirmed that team meetings did not take place, so they did not have the opportunity to discuss concerns and resolve them quickly.

Staff did not feel included in the service. Staff told us that the provider did not communicate clearly and openly with them about their plans for the service. The provider had not engaged with them or given them channels to share their concerns or opinions about the service.

The provider told us about how staff had treated [them]. Staff had often spoken to [the provider] and addressed [them] in a disrespectful manner. They had withheld information about the service from [the provider]. [The provider] did not have access to the computer. The provider told us [they] had struggled to manage the existing staff team.

The provider had not actively and proactively addressed or tackled the issues in the team before they escalated.

We found that the provider had failed to consistently operate the systems in place to support the management of the workforce to ensure their effectiveness. Team meetings did not take place regularly. Records showed some staff had not had an appraisal or a supervision for over one year.

After our inspection, the provider told us [they] had commissioned a Human Resources consultancy company to support with managing personnel.

The provider told us the current staff team were available at short notice to help cover visits. They told us they were coping well as the number of people they supported had reduced significantly.



There were concerns from the local commissioners about the sustainability of the service given the reduced number of people they supported. The provider told us they were working to improve the experiences of the people they were supporting and then they would develop a plan to get more care packages.

The provider had a governance policy in place, but we found that the quality of the service had not been regularly assessed and monitored to identify gaps for improvement.

We found issues with the service’s record keeping as referenced throughout this assessment. For example, records were not always detailed or available. Records were not always complete and accurate such as missing records for known complaints. For some aspects of the service there were no records such as no records of staff inductions. There was no record of a safeguarding allegation made. The provider had not sent CQC a notification about the safeguarding allegation as required. The provider had failed to maintain effective oversight of the service and fulfill their responsibilities as required. One person had consented to staff putting up a bedrail to manage risk of falls. The provider had not documented the consent they had obtained.

Some areas of governance had been completed. We saw audits of medicines completed. We saw records of spots checks undertaken for three staff members to monitor their performance.

There was a business continuity plan in place. This covered major emergency situations including COVID 19 and other disasters. There was a business plan in place. However, the business plan and business continuity plan had not properly identified the issues and risks that may arise from purchasing an existing care company such as managing the workforce, and recruitment issues. There had been concerns with the staff team, and recruiting a manager. They had not planned for an effective strategy to manage change and to support staff through it.

People were supported to maintain contact with their families and the local communities. Staff supported people to prepare for family visits and to go out with them to the community. People and relatives told us about the health care services involved in their care and how staff supported to them to have regular visits from local health care specialists.

Staff worked with health and social care services to meet people’s needs. They told us they liaised with them, made timely referrals, and shared information appropriately. The provider told us they planned to join their local care provider’s forum to build their network of support, learn good practices and keep up to date with information in the sector.

The local commissioners told us that the provider had not always involved them or engaged with them in the planning and developing the service. They commented that they have experienced difficulties contacting the provider. A member of the local commissioning team we contacted told us that the new provider had not planned the purchase of the business with due diligence.

The provider had not consulted or engaged with key partnership agencies in planning and developing the service. They had missed the opportunity to collaborate with them at the start of the service to ensure the service was developed to meet people’s meets and facilitate service improvement.

Staff told us they were not involved in the service. They had not been given the opportunity to share their thoughts about the service to help drive service improvement. Staff told us they were not consulted or encouraged to contribute to the planning and development of the service.

There were no systems or processes in place to review and share learning from incidents, accidents, or complaints. This meant that patterns and trends were not analysed, and actions put in place to mitigate risks, improve practices, or embed learning from lessons when things went wrong. People, their families and staff were not given a platform in which to formally feedback their experiences to drive improvement in the service.

The provider shared an improvement plan they had developed to guide the improvement of the service. They told us the new manager would work closely with staff and people using the service. The provider told us they had recently sent out feedback forms for people and their relatives to complete. People and the relatives we spoke to confirmed this.

The provider had produced an action plan to address some of the concerns in the service. They told us they would work with the new manager to produce a detailed service improvement plan on how to improve the service. They would review various areas of the service and develop an action plan that would also address the breaches of regulations from the last inspection.