27 August 2019
During a routine inspection
Kirkella Mansion is a residential care home providing personal and nursing care to people aged 65 and over and people living with dementia. The service can support up to 40 people. At the time of inspection 24 people were using the service.
People’s experience of using this service and what we found
At the last inspection we found concerns regarding medication management, risk management, infection control, fire safety and good governance. Although some improvements were seen at this inspection we had continued concerns with regards to medication, risk management and good governance.
Medication was not managed safely, we could not be assured people received their medication as prescribed and risks to people were not always mitigated. Accident and incidents were not recorded correctly or monitored effectively so lessons could not be learnt.
Governance systems in place had failed to make the required improvements. Quality monitoring and governance systems had been implemented but were not robust. They had not identified some of the shortfalls identified at this inspection.
People told us they felt safe. There was adequate staff to meet people’s needs. The service was clean, and staff had knowledge of how to prevent the risk of spread of infection.
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. Staff supported people with their health care needs and we received positive feedback from health professionals.
Staff were kind and caring and treated people with respect.
We observed limited activities on offer during the inspection. We made a recommendation regarding the provision of activities. People were happy with the care they received and told us care was delivered in line with their preferences.
People and staff were positive about the management team and the support they received.
For more details, please see the full report which is on the Care Quality Commission (CQC) website at www.cqc.org.uk
Rating at last inspection (and update)
The last rating for this service was requires improvement (published 21 September 2018) and there were two breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection not enough improvement had been made/ sustained and the provider was still in breach of regulations.
Why we inspected
This was a planned inspection based on the previous rating.
Enforcement
We have identified breaches in relation to medication management, risk management and governance systems at this inspection. Please see the action we have told the provider to take at the end of this report.
Follow up
We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.