Kirklees

Updated 13 January 2024

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 Health and Social Care Act 2008.

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 2 inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Kirkless is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Kirkless is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

Inspection activity started on 14 December 2023 and ended on 18 December 2023.

What we did before the inspection

We reviewed information we had received about the service. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send to us with key information about their service, what they do well, and improvements they plan to make. We used this information to plan our inspection.

During the inspection

We spoke with 6 people who used the service and 3 relatives about their experience of the care provided. We spoke with 7 members of staff including the regional manager, registered manager and care workers.

We reviewed a range of records. This included 5 people's care records and 8 medication administration records. We inspected 3 staff files in relation to their recruitment. A variety of other records relating to the management of the service, including audits and policies and procedures, were also reviewed.

We inspected the environment and spent time observing interactions between people and staff, and infection prevention and control practices.

Updated 13 January 2024

About the service

Kirklees is a residential care home providing accommodation and personal care for up to 21 younger adults, older adults who may be living with a learning disability, autistic spectrum disorder, and dementia. At the time of our inspection there were 16 people using the service.

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

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. 'Right support, right care, right culture' is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

Right Support:

Medicine practices were not always in line with best practice guidelines.

People were not supported to have maximum choice and control of their lives, staff did not support them in the least restrictive way possible and in their best interests; policies and systems in the service did not support this practice. Staff did not always follow the Mental Capacity Act key principles when making best interest decisions. We have made a recommendation about this.

People felt staff provided safe care, and systems were in place to report concerns. Staff had been safely recruited and had received training on how to recognise and report abuse and staff knew how to apply it.

Right Care:

The provider had systems in place to report and respond to accidents and incidents. However, not all accidents, incidents or safeguarding concerns had been explored to identify any potential themes, trends or lessons learnt.

People were regularly asked their views on the service provided and action had been taken when suggestions were made.

People were supported to have access to healthcare services to monitor and maintain their health and well-being. We observed kind and caring interactions between people and staff during the inspection.

Right Culture:

There was a lack of effective monitoring in place, and this had resulted in poor outcomes for people using the service. Quality monitoring systems had failed to pick up and address the issues we identified during our inspection.

There was a positive culture within the service. Staff interactions with people were kind and compassionate. Staff knew people well and were responsive to their needs. People and their relatives were involved in their care.

Following our visit to the service, we asked the provider to send us an improvement plan which detailed the actions they had taken/were going to take in relation to the issues identified during our inspection.

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 good (published 2 August 2017).

Why we inspected

This inspection was prompted by a review of the information we held about this service and when the service was last inspected.

We have found evidence that the provider needs to make improvements. Please see the safe and well led sections of this full report.

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

Enforcement and Recommendations

We have identified breaches in relation to medicine management and good governance at this inspection. We have also made a recommendation in relation to consent and person-centred support.

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.