Archived: Kevindale Residential Care Home

Kevindale Residential Care Home is a care home providing support with personal care needs to 13 people at the time of this inspection, some of whom were living with dementia. The home can accommodate a maximum of 14 older people in one adapted building.

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

The provider had made improvements since our last inspection but needed to embed the changes they had made.

The provider had made improvements to the physical environment increasing people’s safety. However, some improvements, regarding staff practices, were still required.

Checks of the emergency equipment were being completed and escape routes were clear.

People had individual assessments of risks associated with their care.

Medicines were stored safely.

Staff followed effective infection prevention and control practices.

The provider followed safe recruitment practices.

The new manager had implemented regular checks to the physical environment.

The provider had delegated oversight of the building to the maintenance manager who reviewed existing systems and introduced procedures for the safe operation of equipment and utilities.

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

Rating at last inspection and update

The last rating for this service was Requires Improvement (published 25 February 2022) and there were 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 we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We undertook this targeted inspection to check whether the Warning Notice we previously served in relation to Regulation 12 ( Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 17 (Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and Regulation 19: Fit and proper persons employed, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met.

The overall rating for the service has not changed following this targeted inspection and remains requires improvement.

We use targeted inspections to follow up on Warning Notices or to check concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance the service can respond to COVID-19 and other infection outbreaks effectively.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Kevindale Residential Care Home is a care home providing support with personal care needs to 13 people at the time of this inspection, some of whom were living with dementia. The home can accommodate a maximum of 14 older people in one adapted building.

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

People were not always safe as the physical environment was not effectively or safely maintained. Fire safety systems had not been routinely checked and the provider failed to identify or mitigate compromised fire safety measures.

The provider did not have effective systems in place to identify environmental issues which could put people at the risk of harm.

The provider did not demonstrate effective infection prevention and control procedures were followed.

The provider did not have robust recruiting systems in place when appointing new staff.

The provider did not have effective quality monitoring procedures to drive good care.

People received their medicines as prescribed. Staff understood how to protect people from the risk of abuse and knew what to do if they suspected something was wrong.

People had assessments of risk associated with their care and support. People had individual personal emergency evacuation plans in place.

The provider had kept us informed about key events and had good working relationships with others involved in peoples care. People and staff told us they found the management team to be approachable.

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 10 September 2021).

At that inspection we found the provider needed to embed improvements required at the previous inspection.

Why we inspected

The inspection was prompted in part due to concerns received about the management of the location. A decision was made for us to inspect and examine those risks.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively. This included checking the provider was meeting COVID-19 vaccination requirements.

You can see what action we have asked the provider to take at the end of this full report.

Following our inspection site visit the provider took action to mitigate the immediate risks to people including conformation of the vaccination status of staff members, fire safety checks and removal of items likely to cause harm.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to keeping people safe, recruitment and the providers monitoring of the provision of care at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and 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.

Kevindale Residential Care Home is a care home providing support with personal care needs to a maximum of 14 older people. Accommodation is provided in an adapted building at ground floor level. At the time of the inspection, 14 people were using the service.

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

Following the last inspection the provider had taken action to ensure staff received the support and training they needed to meet people’s needs. People were protected by the provider’s staff recruitment procedures. People received their medicines when they needed them from staff who were trained and competent to carry out the task. Infection, prevention, control procedures had improved and helped to protect people from the risk of infection. People were protected from the risk of abuse and they told us they felt safe living at the home.

Systems to monitor the quality and safety of the service provided had improved however, more time is needed to ensure systems are embedded and can be sustained over time. Audits had not identified the lack of a care plan for one person who used the service. People were provided with opportunities to express their views about the service they received. The provider was open and honest with people when things went wrong. The provider worked in partnership with other professionals to achieve good outcomes for people.

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

Rating at last inspection (and update)

The last rating for this service was requires improvement (published April 2021) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment, fit and proper persons employed, staffing and good governance.

At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

We undertook this focused inspection to check the provider had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions; safe and well-led which contained those requirements.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has remained requires improvement. This is based on the findings at this inspection.

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

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.

Kevindale Residential Care Home is a care home providing support with personal care needs to a maximum of 14 older people. Accommodation is provided in an adapted building at ground floor level. At the time of the inspection, 14 people were using the service.

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

The provider had failed to protect people against the risks associated with fire safety, scalding and legionella. Environmental audits were not being carried out to ensure that risks to people were minimised.

The provider’s procedures for the management and administration of people's medicines needed some improvements.

Infection, prevention, control procedures did not fully protect people from the risk of infection.

People were at risk of not receiving a service which met their needs and preferences.

The service was not effectively managed and the systems in place to monitor the quality and safety of the service provided were not always effective.

Staff knew how to recognise and report any signs of abuse. People told us they felt safe living at the home and with the staff who supported them.

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 good (published October 2019).

Why we inspected

We identified concerns at recent inspections of two of the provider’s other services in relation to safe care and treatment and good governance. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We looked at infection prevention and control measures under the safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.

Enforcement

For enforcement decisions taken during the period that the ‘COVID-19 – Enforcement principles and decision-making framework’ applies, add the following paragraph: We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and we will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to safe care and treatment, staffing, fit and proper persons employed and good governance.

Please see the action we have told the provider to take at the end of this report.

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

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and 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.

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

People told us they felt safe and staff had enough time to support them. Safeguarding policies and procedures continued to protect people from the risk of abuse and avoidable harm. Risk assessments supported people to manage risks in their daily lives in ways which upheld their rights.

Assessments had identified the support people needed. Not everyone, who may have needed it, had their capacity to consent to receive care assessed. This meant there was a risk people could have been deprived of their liberty without authorisation. People were supported by experienced and skilled staff. Staff had received training and induction; one staff said they had mainly learned by shadowing others. People told us staff were helpful and knew how to support them. People told us they enjoyed the food, which was freshly made and high quality.

Staff were caring and committed to supporting people in ways which upheld their dignity. People told us they felt comfortable when staff supported them with their personal care. Staff communicated well with people and respected their decisions. People's information was stored securely which protected their privacy.

Person-centred care was provided by staff who understood people's needs and preferences. Staff were responsive to any changes in people's needs and wishes. People were invited to participate in their reviews. The service had a complaints policy;, people were aware of this and felt able to raise concerns. Some people felt there were not enough activities, this was in part due to staff vacancies which were being recruited to at the time of inspection.

The management and staff team were committed to providing high-quality care. The management ensured the quality of the service was maintained by regular checks and monitoring. People were encouraged to provide feedback about the service, and the service had responded. The management planned to re-engage with local forums to improve the quality of the service.

Rating at the last inspection

The last rating for this service was good (published March 2017).

Why we inspected

This was a planned inspection based on the previous rating.

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.

Kevindale Residential Care home is registered to provide accommodation and personal care for up to 18 people. At the time of the inspection, there were 12 people living at the home.

There was a registered manager in post who was present throughout the inspection visit. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Confidential personal information about people living at the home and their medicines was not always stored securely. We observed a large amount of paper work in the conservatory next to the dining room. Personal information should be kept secure at all times and only accessed by people who are authorised. A delivery of people’s medicines had been left unsecured overnight in the manager’s office. The door was open and the medicines were available to anyone passing the room.

Staff understood the importance of ensuring that people were safe and were able to explain their responsibilities for reporting any accidents or concerns. Where risks were identified, action plans were in place to minimise the risk and keep people safe.

We found there were sufficient numbers of staff on duty during our inspection to support people who used the service. People told us there were enough staff on to meet their needs.

People were protected from the risk of harm and abuse by staff who knew how to recognise and respond appropriately to any concerns that they had.

People received support with their medicines from staff who were assessed as competent and followed safe practice with medicines.

Staff had the skills and knowledge needed to meet people’s individual care needs. They received effective induction, training and on going support from the registered manager. The registered manager understood and protected people’s rights under the Mental Capacity Act 2005.

People had their nutritional needs assessed and were supported to have the right amount of food and drink to maintain good health.

Staff supported people in a caring, respectful and dignified way, and were able to demonstrate a good understanding of the people they supported.

People and relatives told us they were involved in making decisions about their care and were listened to by the registered manager. They told us they had been involved in determining the care they needed and had been consulted and involved when changes were needed. People and staff felt able to express their views and felt their opinions mattered.

There was a positive and inclusive culture in the home where the staff worked together as a team to ensure people's needs and wishes were met. The registered manager had checks in place to monitor the quality of the service delivery. There were systems in place to encourage people to share their experiences and concerns.