Kavanagh Place

Updated 24 June 2021

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by two inspectors.

Service and service type

Kavanagh Place is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service did not have a manager registered with the Care Quality Commission. An interim manager was in place at the home whilst recruitment for anew manager was completed. This means that the provider is legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was unannounced.

What we did before inspection

We reviewed information we had received about the service since the last inspection and we sought feedback from the local authority. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We used all of this information to plan our inspection.

During the inspection

We spoke with two people who used the service and three relatives about their experience of the care provided. We spoke with seven members of staff including the manager, regional manager, senior care workers, care workers and maintenance staff.

We reviewed a range of records. This included four people’s care records, and multiple medication records. We looked at three staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were also reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found.

Updated 24 June 2021

About the service

Kavanagh Place is a residential care home providing nursing and personal care to 38 people at the time of the inspection. The service is registered to support up to 42 people. 40 people are supported in one adapted building located across four units over two floors, and a further two people are supported in separate accommodation situated off the main site across the road.

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

People had personalised risk assessments which gave staff the information needed to safely manage the risks associated with people’s care. There were some inconsistencies with the recording of some of the care being delivered, however we were assured people had their needs met safely. The provider told us they would address recording concerns immediately.

People received their medicines safely and as prescribed. Medicines were stored safely and audited regularly to ensure good practice was maintained. We found two recording errors during the inspection which the provider thoroughly investigated and appropriate action was taken to minimise the risk of repeated errors.

Accidents and incidents were recorded, and actions were in place to ensure people were safe. Referrals were made to healthcare professionals when needed to ensure good outcomes for people.

The environment was safe and well-maintained. The home was clean and effective infection prevention and control measures were in place. Some areas of the home were not as well maintained as others, however there was a programme of refurbishment underway during the inspection which included the areas of concern.

There were enough staff at the home to meet people’s needs. Staff were visible around the home and were readily available to support people when needed. Staffing levels were monitored, reviewed and amended when needed by the manager.

People were safeguarded from the risk of abuse. Staff had received safeguarding training and understood their role in recognising and reporting safeguarding concerns. The provider had appropriate systems in place to manage concerns of a safeguarding nature.

There was a kind and caring culture. Staff knew the people they supported well and we observed many positive interactions throughout the inspection. Relatives spoke of staff going above and beyond their duties to support their loved ones in a caring and compassionate way. One relative said, “I can’t explain how happy I am with way [person] is treated, it’s like [person] is one of the family. The care is second to none.”

There had been multiple changes within the management team since the last inspection. The provider ensured there was appropriate management cover during this period. Relatives told us they felt communication with the home could be improved as they were not always aware of changes at the home and did not feel they always got a response to queries.

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 29 August 2018).

Why we inspected

We undertook this targeted inspection to follow up on specific concerns which we had received about the service. The inspection was prompted in part due to concerns received about staffing levels, leadership of the service and environmental concerns. A decision was made for us to inspect and examine those risks.

We inspected and found there was a concern with the environment and aspects of the governance of the service so we widened the scope of the inspection to become a focused inspection which included the key questions of Safe and Well-led

This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

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.

The ratings from the previous comprehensive 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 remains good. 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 Kavanagh Place 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.