Kestrel House

Updated 19 March 2021

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.

As part of CQC’s response to the coronavirus pandemic we are looking at the preparedness of care homes in relation to infection prevention and control. This was a targeted inspection looking at the infection control and prevention measures the provider has in place.

This inspection took place on 4 March 2021 and was announced.

Updated 19 March 2021

This inspection took place on 7 November 2018 and was announced. At our last inspection in August 2017 we found the provider in breach of regulations relating to safeguarding, safe care and treatment, staff training and governance. We took enforcement action and issued requirement notices for safeguarding and staffing and served a warning notice for safe care and treatment. Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions to at least Good. The provider sent us an action plan detailing how they were going to address these concerns. At this inspection we found the provider had made the necessary improvements.

Kestrel House is a ‘care home’. People in care homes received 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. Kestrel House accommodates up to 19 people, with mental health needs, in one adapted building. At the time of our inspection there were 19 people living at the home. Each person has their own room with shared communal facilities, including bathroom, living and dining area and communal garden. There is an office on the ground floor and arrangements in place for staff to sleep in.

There was 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.

People were protected from the risk of abuse because systems were in place to protect them. Risks to people were assessed and people supported to stay safe and their freedom respected. There were sufficient numbers of staff on duty to meet people’s needs. Since our last inspection in August 2017 the provider had increased staffing levels. Medicines were now managed and stored safely. People were protected from the risk of infection because the service followed infection control practices and staff were provided with the necessary personal protective equipment. Systems were in place to learn and make improvements to the service following an accident or incident.

People’s needs were assessed and care and treatment delivered in line with people’s plan of care.

Staff were supported to ensure they had the necessary skills, knowledge and experience to effectively provide care and support. People were encouraged to eat and drink enough to maintain a balanced diet. The service worked within the legal requirements of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. Staff understood the need to ask people for their consent before providing care and treatment. People had access to other healthcare professionals to ensure their healthcare needs were met.

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 were treated with dignity and respect and their privacy maintained. People’s independence was promoted.

The service had a complaints procedure in place and we found that complaints were investigated and where possible resolved to the satisfaction of the complainant.

Staff told us the registered manager was approachable and listened to concerns. The service had improved the way they carried out quality assurance and monitoring of the service.

We made two recommendations relating to staff recruitment and staff training.