Kilkee Lodge Residential Home

Kilkee Lodge Residential Home is a care home which provides accommodation with personal care for up to 80 people. At the time of the inspection the service was supporting 76 people accommodated in 1 adapted building on 2 floors.

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

Audits on quality and safety had improved since the last inspection, However, further improvements were needed to ensure oversight of hygiene, refresher training, risk assessments and complaints process.

Assessments were completed and risks to people’s health and wellbeing had improved. However, there was no oversight that these had been completed correctly. Comments and concerns raised by people and family members were not always recorded appropriately so that lessons could be learnt, and improvements made.

Kilkee Lodge was providing a rehabilitation service where people used the service to gain independence skills to return home. However, there was no clear protocol or guidance for how this was provided. The provider's statement of purpose needed to be updated.

Infection prevention and control measures were in place; however, some improvements were needed to areas of the service to ensure they were odour free. Some facilities such as 2 of the bathrooms were not able to be used by people as they needed attention.

Medicines were managed in line with professional guidance and people received their medicines as prescribed. Systems were in place to manage safeguarding concerns and staff were clear about the actions they should take, where they had a concern.

The deployment of staff and rota arrangements had been improved and met the needs of people using the service. There were enough staff on duty to provide appropriate care and support to people living at Kilkee Lodge. Staff were safely recruited to work at the service and were inducted and trained to provide good care.

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 were responsive to people’s needs. People were able to participate in social and leisure activities provided by the service. People were given appropriate care and support at the end of their lives.

The management team were accessible and clear about their roles and responsibilities. They supported staff who were consistent, kind and caring. The management and staff team had developed positive working relationships with external stakeholders and other healthcare professionals. Lessons had been learnt when things had gone wrong.

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 17 May 2021) and there were 2 breaches of the regulations. The provider completed an action plan after the last inspection in April 2021 to show what they would do and by when to improve. At this inspection there was not enough improvement, and the provider was still in breach of the regulations.

At our last inspection we recommended the provider review the deployment of staff to ensure staff were available to respond to requests for assistance. At this inspection we found the provider had acted on the recommendations and improvements had been made.

Why we inspected

We undertook this unannounced 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 of Safe, Responsive and Well led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has remained requires improvement based on the findings of this inspection.

We have found evidence the provider needs to make improvements. Please see the well led section of this full report.

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

Enforcement and Recommendations

We have identified a breach in relation to good governance at this inspection.

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

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

Kilkee Lodge Residential Home is a care home which provides accommodation with personal care for up to 80 people. At the time of the inspection the service was supporting 76 people.

Rating at last inspection

The last rating for this service was Good (published 30 April 2019).

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

Risks were not always assessed or effectively managed to keep people safe. Staff were not provided with clear guidance on risks such as those associated with moving and handling should be managed.

People told us staff were kind and helpful but gave us mixed views on how the availability of staff. We have recommended the deployment of staff is reviewed to ensure staff are available when people need support.

There were processes in place to check on the suitability of staff prior to them starting work at the service however staff training was not always up to date.

Medicines were not always managed in line with professional guidance. The manager told us that the risk would be reduced as the service was due to implement a new medication administration system.

There were arrangements in place to manage safeguarding concerns and staff were clear about the actions they should take, where they had a concern.

There were systems in place to manage infection control. The provider was following the government’s guidance on whole home testing for people and staff. This included rapid testing and weekly testing. Visits by relatives had been facilitated to the service which was welcomed by staff and people using the service. We identified some areas where improvements were needed and have signposted the provider to resources to develop their approach.

A new manager had recently started work at the service and staff told us they were helpful and approachable. Audits on quality and safety had not been consistently completed and those in place had not identified the shortfalls we found in areas such as medication, training and care planning.

Why we inspected

We inspected because the service had a recent COVID-19 outbreak and some concerns had been raised. We carried out an inspection to examine those risks.

During the course of the inspection we widened the scope of the inspection to a focused inspection which included the key questions of Safe and Well led.

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.

We have found evidence that the provider needs to make improvements. Please see the Safe and Well Led sections of this report. You can see what action we have asked the provider to take at the end of this report.

The overall rating for the service has changed from Good to Requires Improvement. This is based on the findings at this inspection.

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.

People’s experience of using this service:

The service met the characteristics of good in most areas. We did identify some shortfalls with staffing as people had to wait for support. During the course of the inspection the registered manager increased staffing levels.

We also identified shortfalls in documentation and the service was in the process of moving from a paper to an electronic system. We saw staff provided good care, but this was not always reflected in the written records. We have recommended that staff receive more training on using the new electronic recording system.

People told us they enjoyed the food and meals looked attractive.

There were clear systems in place for the ordering, administration and monitoring of people’s medicines.

Communication with health and social care professionals was effective in ensuring that people received joined up care. We have recommended that further work is undertaken to ascertain peoples wishes at the end of their life.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People had access to activities to enhance their wellbeing and told us that staff were kind and helpful.

Incidents and accidents were recorded and reviewed to prevent a reoccurrence.

The service was clean and there were systems in place to check on equipment to ensure that it was safe. We have recommended that the provider review exit doors, as they were not alarmed, in line with the needs of the people resident in the service.

The registered manager understood their responsibility under the duty of candour to be open and to take responsibility for things that go wrong. There were oversight systems in place to audit and check on the delivery of care. The service worked with ‘Prosper’ which is a local multiagency project which aims to improve safety in care homes and reduce falls and pressure ulcers.

People’s views on the service were sought in several ways and used to help make improvements at the service.

Rating at last inspection: At our last inspection, the service was rated ‘Requires Improvement'. Our last report was published on 27 April 2018.

Why we inspected: This was a planned inspection based on the rating at the last inspection.

Follow up: We will continue to monitor all intelligence received about the service to ensure the next planned inspection is scheduled accordingly.

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

Kilkee Lodge 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. Kilkee Lodge is registered to provide care and support for up to 80 older people. The service is located in Braintree and the care and support provided in a purpose built building over two floors. There were 70 people living in the service when we inspected.

The service had a registered manager who had been appointed and registered since the last inspection. 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.

At our last inspection of the service on 14 December 2016, we rated the service as "Requires Improvement" overall. This was because we found shortfalls in the way medicines, risks and nutrition were overseen and managed. We found that the provider was in breach of a number of the regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Following the inspection the provider sent us an action plan setting out the actions they intended to take to ensure improvement. At this inspection we found that improvements had been made and the service was no longer in breach of the regulations we identified in the 2016 inspection. However we concluded that further work was still needed to ensure consistency of practice across the service. The service remains rated as “Requires improvement.”

Improvements had been made to medicine administration and there was a clear process in place for ordering, receiving and disposal of medicines.

There were systems in place to mitigate risks to people. Risk assessments were in place which set out how risks should be managed and the likelihood of harm reduced. People had access to a range of specialist equipment, such as pressure relieving mattresses to reduce the likelihood of them developing skin damage. Moving and handling risk assessments were in place but we have recommended that further advice is sought from occupational therapy about the use of specific slings. The environment was regularly monitored and checks were undertaken on equipment to reduce the likelihood of equipment failure.

People gave us mixed views on staffing levels and told us that there was not always enough staff available. Staffing rotas showed variable numbers of staff on duty on some days. There was a dependency tool in place to assess overall staffing levels and according to this tool there were sufficient staff employed. We have recommended that further analysis is undertaken to ensure that the staffing levels fully meet people’s needs.

Staff received training on how to recognise abuse. There were systems in place to review incidents and identify learning.

There were clear processes in place to check on staff suitability prior to them starting work at the service which included references and disclosure and barring checks. The new registered manager had reviewed the training which was previously undertaken and commissioned additional areas. There was an induction, training and development programme, which supported staff to gain relevant knowledge and skills. Staff received supervision to support them in their role and identify any learning needs and opportunities for professional development.

The service was clean and there were systems in place to control infection. However parts of the service were cluttered and some equipment in need of replacement which meant that they were difficult to keep clean.

People had good access to drinks and there were clear systems in place to monitor to those individuals at risk of malnourishment. Feedback on the quality of the meals was overwhelmingly positive.

The Mental Capacity Act (MCA) 2005 provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The registered manager understood their responsibilities in regard to the legislation and was working with staff to develop their knowledge.

People had good access to health care and the staff worked to health professionals to promote people’s needs. We have however recommended that more formal systems of communication are developed to ensure continuity of care.

Staff spoke highly of staff and told us that they were kind and compassionate in their approach. People looked well-groomed and were wearing communication aids such as spectacles and hearing aids. There were good systems in place to support people to express their views about the quality of the service. The registered manager responded to suggestions from people and their relatives in a positive way.

Care plans were not always sufficiently detailed and while there were systems in place to monitor people’s needs these were not always working effectively. This meant that there were risks that changes in people’s needs may not be recognised or actioned appropriately.

People had access to a range of stimulating and interesting activities which they enjoyed. The service had built up good relationships with community groups. There were no activities at weekends but the registered manager told us that they were expanding the activities available.

Concerns and complaints were investigated and used to identify learning.

Staff and relatives were all consistently positive about the new registered manager and the progress and changes made since the last inspection. They told us that they were visible an approachable and staff morale had improved.

The registered manager completed a range of audits to monitor the safety and quality of the service. We found that whilst improvements have been made in some areas, there was still some way to go to ensure consistency of care across the service. There remained gaps in recording and there was a lack of oversight. Audits were not always identifying issues.

During this inspection we identified a breach 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

The service did not have a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 previous registered manager left the service in September 2016 and another registered manager working for the provider has been managing the service. They returned to manage the service where they are registered in early December. Throughout this period an experienced deputy manager has been working at the service. A new manager has been appointed and will commence at the service in January 2017 and the provider informed us that they would be seeking registration with the (CQC).

Kilkee Lodge is a care service over two floors with dining and communal rooms for the use of the people that use the service. Work had recently taken place to develop and refurbish the upstairs dining room and experience for people using the service. The entrance way had some information available about the service for example, but we found this was limited. For example there was no complaints process displayed, but there was a suggestion box available, however we noted there were no forms to fill in. The corridor flooring on the ground floor was unclean in places, but the cleaning staff tried their best to keep this flooring clean as it was difficult to maintain. We found the people's rooms we saw, were clean and odour free, as were the communal rooms, bathrooms and lavatories.

People were not always safe because the service had made an error with the recording of medicines, but this has no impact upon the well-being of the person. When people fell this had not always analysed, or the care plan for reducing the falls had not followed. For example some people required supervision but were left alone. We saw one person lying in bed and their catheter was on the floor instead of being housed in a catheter stand. Although this was not necessarily a trip hazard, it was a concern with regard to effective infection control.

Staff had been recruited safely and had received training in a number of core subjects. Recruitment was on-going to fill staff vacancies which were covered by agency staff. Having to induct new agency staff into the way the service worked was demanding for all of the regular staff and they looked forward to a time when the service was fully recruited.

The deputy manager carried out dependency level assessments from the information provided by the staff team to calculate the number of staff required to provide care and support to people using the service. Although the staffing compliment on the rota was in agreement with the number of staff required, regular staff considered they were pushed to provide the care required when working with agency staff unfamiliar with the service. The deputy manager tried to use known agency staff to cover staff vacancies and this was usually successful.

Some people considered that there should be more staff on duty and in particular would have liked more activities. Other people spoke very highly of the staff and the service. We did hear call bells being used on many occasions during our inspection which were answered usually within a short period of time. However we did observe people being left in communal lounges for periods of time with no staff present.

The service had increased the number of staff employed at senior care levels since our last inspection. The deputy manager told us the staff team was stable with many staff having over ten years dedicated experience of working at the service.

Following a visit from the Essex County Council Contractual Compliance team in September 2016 the service had responded to areas of concern identified. The senior staffing levels had been increased and additional training and supervision sessions for staff had been provided. The staff we spoke with told us that they were supported in their roles and had received training in various subjects how to recognise and respond to allegations of abuse.

We have made a recommendation in this report about the need to check the information in each care document for accuracy. This was because a care plan and daily record regarding the frequency of a person being re-positioned, two or four hourly were not in agreement. This was also the case for moving and handling, although we were confident from our observations and talking with staff about their training knowledge and skill for moving and handling. We have therefore also made a recommendation for the clear recording of moving and handling people in their care plan.

The service was meeting the requirements of the Deprivation of Liberty Safeguards (DoLS). Appropriate mental capacity assessments and best interest decisions had been undertaken by relevant professionals. This ensured that the decision was taken in accordance with the Mental Capacity Act (MCA) 2005, DoLS and associated Codes of Practice. MCA, Safeguards and Codes of Practice are in place to protect the rights of adults by ensuring that if there is a need for restrictions on their freedom and liberty these are assessed and decided by appropriately trained professionals. People at the service were subject to the Deprivation of Liberty Safeguards (DoLS). Staff had been trained and had a good understanding of the requirements of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.

Regular staff knew people well and it was reported to us the staff were kind and compassionate.

We saw examples of staff supporting people discreetly with regard to using the lavatory. However the care was not always person-centred with regard to when people could have a bath. The service arranged to offer people a bath upon a weekly rota system sometimes more than once based upon the individuals choice.

The service carried out assessments of people’s needs to determine if the service could provide the support the person required prior to them coming the service. The care was reviewed on a monthly basis and when required. However although the service had identified that a person could become excitable in their behaviour, there was not an analysis as to why and the how the staff were to respond was not sufficiently detailed.

We have a recommendation that when reviewing peoples care their hand and nail cleanliness is included and action taken as required.

The service handovers from shift to shift were well organised allowing staff time to raise questions and clear information given for what the staff were to achieve in the forthcoming shift.

There were two complaints policies in use in the service and we have made a recommendation about the management of complaints.

Although we saw people enjoying Christmas facilities and singing with an entertainer on the day of our inspection, people told us that there was a lack of activities for them to do over the seven day period.

The deputy manager provided consistent supportive management to the staff and knew the people who used the service. The day to day monitoring and auditing was not as reliable as required, no doubt in some way due to the changes of management within the service.

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

Where some people had complex needs and were unable to tell us about their experiences, we used observation and noted individual's responses to staff. We noted that people appeared calm and relaxed. We saw that staff supported people in a patient and sensitive manner.

There were policies and procedures, records and monitoring systems in place for the protection of people who used the service.

There were systems in place to ensure people were qualified to provide care and support for people.

We found that the provider had systems in place to monitor and respond to any concerns or complaints received by the home.

During this inspection we spoke with ten staff, including the manager. We observed care being provided, spoke with one relative and spoke with eight people using the service. We looked at one care plan, and other records which showed us how care was being provided.

We found the service had complied with all but one of the regulations inspected. People were asked for their views about their care. Records clearly described people's care needs and how they should be met by staff. People told us they were satisfied with how the service was delivered. One person said, "I am happy here, my needs are understood and met. I wish I had come in earlier." Another person told us, "Staff always ask me if I want to join in with the activities provided and will assist me if I need help, but I like my independence."

We saw improvements had been made in the way staff were supported through induction, supervision and training to ensure they were competent to meet people's needs. We still had concerns about the management of the service and have made a further compliance action but assessed the risk has been reduced to a minor concern.