CQC report explained · a residential care home
What the CQC found at Kathleen House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Staffing, recruitment, medicines administration and infection control were generally managed safely, although medicine stock-control records were not used consistently.
- Effective?
- Good
- People received care from staff with suitable skills and knowledge. Staff supported nutrition, healthcare and least restrictive care, although some care arrangements had not been updated in records.
- Caring?
- Good
- Staff were kind and respectful and supported people's dignity, privacy, independence and communication. People were offered choices and involved in decisions about their care.
- Responsive?
- Good
- Care plans reflected people's needs and preferences, and staff knew people well. Relatives said concerns were listened to and addressed, and people were supported with activities and their chosen lifestyles.
- Well-led?
- Good
- The home had effective quality checks and an approachable manager. However, one DoLS notification was sent retrospectively, medicine stock-control systems were not always followed, and the development plan needed clearer central recording.
What inspectors found, May 2019
Rated Good, improved from Requires Improvement; inspectors found kind, safe care with some records and medicines-monitoring issues.
This was an unannounced inspection on the first day and an announced inspection on the second. The inspector spoke with people, relatives, staff, the manager and provider. They also reviewed care, medicines, recruitment and management records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People appeared comfortable and relaxed. Inspectors found staff were kind, knew people well, supported choice and worked with health professionals.
There were some areas to improve. A few care records had not been updated after changes. Medicine stock checks were not always used consistently, one notification to CQC was sent late, and the home's improvement plan needed clearer recording. The previous rating in June 2017 was Requires Improvement.
Kind and respectful staff
Inspectors saw staff treating people kindly and with respect. People appeared comfortable and relaxed with staff.
“We saw staff were kind and respectful to people and we observed some thoughtful and caring acts by staff during our inspection.” from the report
Good knowledge of people
Staff understood people's needs, preferences and communication methods. Care was personalised and based on people's choices.
“Staff were knowledgeable about people; their needs and preferences and we saw they had a good relationship with the people.” from the report
Safe staffing and recruitment
Inspectors found enough staff to meet people's needs and saw staff responding when people needed help. Recruitment checks, including DBS checks, had been completed before staff started.
“We saw there were enough staff to meet people's individual needs, and we saw staff were responsive to people when they needed assistance.” from the report
Support for health and nutrition
Staff worked with healthcare professionals and supported people to eat and drink safely. People were offered food and drink choices.
“The staff worked with other healthcare professionals to ensure positive outcomes for people, for example, there was regular reviews by speech therapists in respect of those people at risk from choking.” from the report
Medicine stock checks
needs fixingThe system for checking medicine stocks was not always used consistently by staff. The manager said this would be raised with staff.
“However, we found the system for stock control of medicines was not consistently used as it should be by staff.” from the report
Care records not always updated
minorSome changes to care arrangements had not been recorded in updated care plans. Staff knew people's current needs, so inspectors said this had not affected people at the time.
“While we did find some limited instances where changes in care arrangements had not been updated, this had not impacted on people as staff demonstrated they were well informed of what people's current needs and wishes were.” from the report
Late CQC notification
needs fixingThe home did not initially tell CQC about the approval of a DoLS application. It sent the notification later, retrospectively.
“However, we found they had not informed us of the approval of a DoLS application.” from the report
Improvement plan records
minorThe home's development plan did not clearly bring together audit findings and actions in one central record. Inspectors said clearer recording would make monitoring simpler.
“However, more clarity of the home's development plan was required.” from the report
- 01How do you now check medicine stocks, and how do you make sure staff consistently record and act on those checks?
- 02How are changes in a person's care needs recorded and shared with staff?
- 03What has been done to ensure all required DoLS notifications are sent to CQC on time?
- 04Can you show how audit findings and improvement actions are now brought together in one development plan?
- 05Which staff training updates were still planned or in progress at the inspection, and have they now been completed?
This was a planned comprehensive inspection covering all five key questions; the previous overall rating was Requires Improvement in June 2017. This explanation was written from the published report of 2 May 2019 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, June 2017
Rated Requires Improvement; inspectors found kind, responsive care but gaps in risk procedures and records.
This was an unannounced inspection on 4 and 8 May 2017. Two inspectors and an expert by experience spoke with people, relatives, staff and healthcare professionals. They reviewed care records, medicines, recruitment, training, complaints and quality checks.
The home was rated Good for Effective, Caring and Responsive. People were treated kindly, supported to make choices, given enough food and drink, and helped to access healthcare and activities.
Safe and Well-led were rated Requires Improvement. Staff did not always follow risk procedures, including safe equipment use. Some care, medicines and management records were incomplete or out of date. Improvements had been made since the March 2016 inspection, but inspectors said further work was still needed.
Kind and dignified care
Inspectors saw staff treating people respectfully and promoting their privacy and dignity. People and relatives described staff as caring and attentive.
“People were supported by staff who were kind and treated people with dignity.” from the report
Meaningful activities
People were supported to take part in activities they enjoyed, including gardening, baking, trips and holidays.
“People were supported by staff to do the things they enjoyed.” from the report
Food and healthcare
People had enough to eat and drink, were offered choices, and were supported to attend healthcare appointments. Staff followed advice about swallowing and other dietary needs.
“People had access to sufficient food and drink, and support from staff to monitor their healthcare needs.” from the report
Improved recruitment and training
The recruitment files checked contained the required checks before staff started work. Staff had access to induction, training and supervision.
“At this inspection, we spoke with a newly recruited staff member who confirmed that reference checks and Disclosure and Barring Service (DBS) had been undertaken before they had started work.” from the report
Risk procedures were not always followed
seriousA bedrail was fitted without management authorisation, risk assessments or specific staff training, and it caused a minor injury. Staff were also sometimes using a sling that professional advice said should not be used.
“We found this bedrail had been fitted without the authorisation of the registered manager and risk assessments were not completed to ensure they were safe for this use.” from the report
Records did not always give clear guidance
needs fixingSome care records and risk assessments had not been updated after people's needs changed. Guidance about equipment and some medicines was incomplete.
“Some records were not always accurate and up to date.” from the report
Medicines records and guidance had gaps
needs fixingSome medicine administration records were not signed for testing strips and a prescribed cream. Not all medicines given when needed had protocols explaining the signs and triggers for use.
“We found some gaps in the MARs where a person's testing strips and a prescribed cream had not been signed out, this was raised with the registered manager.” from the report
Electrical safety checks were overdue
needs fixingTesting of electrical appliances was overdue when inspectors visited. The registered manager said this had been raised with the provider.
“However we found that the testing of electrical appliances was overdue.” from the report
- 01What has been done to make sure staff always follow professional advice about slings and other moving equipment?
- 02How do you authorise, assess and monitor any bedrails or other equipment that could restrict a person's movement?
- 03Have all care records and risk assessments been updated to reflect current needs and give staff clear instructions?
- 04Do all medicines given when needed now have written guidance about the signs and triggers for use?
- 05Has the overdue electrical appliance testing been completed, and how much management time is now available for quality checks and record updates?
This was an unannounced inspection covering all five rating areas; inspectors spoke with nine people, six representatives and staff, and reviewed samples of care, medicines, recruitment and management records. This explanation was written from the published report of 22 June 2017 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Kathleen House
3 rated inspections over 3 years: the service has improved, from Requires improvement to Good.
- May 2019Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- September 2014
Report published without a new overall rating.
- April 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- September 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 19 November 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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At least 100 live-in carers within about an hour of Dudley
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Most charge £980 to £1,230 a week. 88 can care for a couple. 10 years' experience on average.
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