Archived: Kathleens Lodge

Updated 4 August 2015

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, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

The inspection took place on 26 May and was unannounced.

Two inspectors and an expert by experience undertook this inspection. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service. At this inspection the expert by experience had knowledge of the needs of older people living with dementia.

We checked the information that we held about the service and the service provider. This included previous inspection reports and statutory notifications sent to us by the registered manager about incidents and events that had occurred at the service. A notification is information about important events which the service is required to send to us by law. We used all this information to decide which areas to focus on during our inspection.

On this occasion we did not ask the provider to complete a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make.

On the day of our inspection, we spoke with six people using the service and five relatives. We spoke with the registered manager, the provider, a senior carer, the chef and three carers. We looked at people’s care records, staff files, medical administration record (MAR) sheets and other records relating to the management of the service. We contacted local health professionals who have involvement with the service, to ask for their views. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

The last inspection took place on 23 October 2013. The home was fully compliant with all outcomes inspected and there were no outstanding compliance actions or enforcement action.

Updated 4 August 2015

We inspected Kathleens Lodge on 26 May 2015. Kathleens Lodge is a residential care home that provides accommodation and support for up to twenty people .The people living there are older people with a range of physical and mental health needs. Most people living at Kathleens Lodge are people who are living with dementia. The home does not provide nursing care. On the day of our inspection there were eighteen people living at the home. Kathleens Lodge is a large detached house set back from a main road. It has a large patio and garden area for people to access.

The service had a registered manager in post. 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.

The registered manager and provider had a good oversight of the running of the home and a thorough knowledge of the people that lived there. However there was no clear system of quality assurance in place that audited practice within the home in order to help ensure continuous improvement. This is an area that we have identified that requires improvement.

People who lived at Kathleens Lodge were not consistently safe. They were cared for by staff that knew them well and were aware of the risks associated with most of their care needs. Staff were aware of the potential signs of abuse and who to report this to.

Risk assessments were not carried out for everyone regarding the use of a stair gate which could be restrictive for some of the people living there, limiting their movement. On the day of our visit there were not always enough staff on duty. We have identified these as areas that require improvement.

We could not see that people were informed or consulted regarding the use of CCTV in the home. We have identified this as an area that requires improvement.

The registered manager and staff had received training about the Deprivation of liberty safeguards (DoLS). People who required a DoLS had been referred to the local authority for assessment.

Consent was sought from people with regard to the care that was delivered. Staff understood about people’s capacity to consent to care and had received training in this area.

Staff were appropriately trained some of whom held a Diploma in Health and Social Care. All staff had received essential training. Staff had received training in supporting people living with dementia. Staff had started a new recommended training called The Care Certificate which provides a benchmark for training in adult social care.

People could choose what they wanted to eat from a daily menu. One person said “You feel like the food is nourishment”. People were asked for their views about the food and were involved in planning the menu. They were encouraged and supported to eat and drink enough to maintain a balanced diet.

Staff knew people well and were aware of their individual needs. One person said “They know me and what I like”. They interacted with people with warmth and humour. They told us they respected people’s privacy and dignity and we saw this on the day of our inspection.

We observed activities taking place but could not see how individual one to one activities were planned for people living with dementia. We have made a recommendation regarding this and it is an area that needs improvement.

We found breaches of the Health and Social care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.