Kacee Lodge

Updated 6 March 2021

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

As part of CQC’s response to the coronavirus pandemic we are looking at the preparedness of care homes in relation to infection prevention and control. This was a targeted inspection looking at the infection control and prevention measures the provider has in place.

This inspection took place on 27 January 2021 and was unannounced.

Updated 6 March 2021

About the service

Kacee Lodge is a residential care home registered to provide accommodation with personal care for up to seven people with learning disabilities, and who may also have an autistic spectrum disorder. The service does not provide nursing care. At the time of the inspection six people were living at the service.

Kacee Lodge is a domestic style single storey detached house within a residential area of Colchester. Each person has their own bedroom and access to additional communal facilities, including a purpose built sensory room. The design of the building fits into the residential area and is like other domestic homes of a similar size. There were deliberately no identifying signs, intercom, cameras, industrial bins or anything else outside to indicate it was a care home. Staff were also discouraged from wearing anything that suggested they were care staff when coming and going with people.

The service has been developed and designed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. This ensures that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence. People using the service receive planned and co-ordinated person-centred support that is appropriate and inclusive for them.

People’s experience of using this service and what we found

At our last inspection we recommended the provider reviewed their arrangements relating to their quality assurance processes, to ensure they meet best practice guidance and relevant legislation, and ensure staff were properly trained, had regular supervision and an annual appraisal of their overall performance. The provider had made these improvements.

However, further improvements were needed to ensure the governance systems used by the registered manager at local level were effective. These had not identified the issues we found during this inspection in relation to safe recruitment, cleanliness of the laundry and failed to recognise and address people’s protected characteristics.

Although the majority of staff had worked at Kacee Lodge for a long time, a review of recruitment files found, references from previous employers had not always been obtained to confirm their fitness to work at the service. Additionally, where previous convictions had been disclosed on a staff’s disclosure and barring service check, the registered manager had not explored these issues to ensure they were not a risk to the vulnerable people in their care.

We have made a recommendation about the safe recruitment of staff.

Further work was needed to promote people’s protected characteristics, such as age, disability, race, religion or belief, and sexual orientation. People had not been involved in deciding who provided their care, including their preference for male or female staff.

We have made a recommendation about people’s protected characteristics.

The premises need modernising. The provider had a plan in place for refurbishment of the service over the next 12 months, and some progress had already been made in relation to fire safety and replacement flooring throughout the premises. The registered manager took immediate action during the inspection to refer issues about the laundry flooring to the estates team, and ensure it was cleaned to prevent the risk of spreading infection.

Staff had good understanding safeguarding procedures and how to report concerns. Medicines management and risks to people were assessed and managed well. The service had worked well liaising with other professionals and services to ensure people received the support they need to stay safe. Staff understood how to support people’s anxieties and behaviours in a positive way.

Staffing levels were sufficient to meet people's complex needs. Staff and records confirmed they had received a range of training to give them the skills and experience to carry out their roles.

Where things have gone wrong, systems were in place to learn from such incidents and improvements made. Improvements had been made since our previous inspection to ensure people's personal monies were accounted for.

Staff were aware of people’s specific health needs. Changes in people’s care and support needs were identified and responded to promptly. People were being supported to live a healthy lifestyle and had access to food and drink of their choice. Work was in progress to develop end of life care plans to ensure people’s wishes are considered at such time, and ensure they experience a pain free and comfortable death.

The requirements of the MCA and DoLS were understood and managed in line with relevant guidance and legislation. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

The service applied the principles and values of Registering the Right Support and other best practice guidance. These ensure that people who use the service can live as full a life as possible and achieve the best possible outcomes that include control, choice and independence. The outcomes for people using the service reflected the principles and values of Registering the Right Support by promoting choice and control, independence and inclusion. People's support focused on them having as many opportunities as possible for them to gain new skills and become more independent. People were supported to access colleges and activities, such as ‘bounceability’ to improve their fitness, however we found little evidence to reflect people had access to community-based activities on a regular basis that were socially and culturally relevant to them.

People using the service were well cared for, by staff that knew them well. People were involved in making decisions about their care and how their home was decorated. People had good access to advocacy support where needed to support them when making important decisions. The service was meeting the requirements of the Accessible Information Standards (AIS) which ensured people were provided with information in a way they can understand.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection: The last rating for this service was requires improvement (published 22 November 2018).

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Kacee Lodge on our website at www.cqc.org.uk.

Why we inspected

This was a planned inspection based on the previous rating. The inspection was also prompted in part by notification of a specific incident, following which a person using the service sustained a serious injury. The information CQC received about the incident indicated concerns about the management of scalding. This inspection examined those risks. The provider had taken immediate action to mitigate the risks of a similar incident happening again, and we found no evidence during this inspection that people were at risk of harm from this concern. Please see the safe section of this full report.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.