CQC report explained · a residential care home
What the CQC found at Kathleens Lodge Rest Home Ltd
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Inspectors found enough staff, safe recruitment, suitable risk guidance, clean premises and medicines that were safely stored and administered.
- Effective?
- Good
- Staff had training and support to meet people's needs. People had access to healthcare, nutritious food and help to make choices in line with the Mental Capacity Act.
- Caring?
- Good
- Staff treated people with kindness, dignity and respect. People and relatives said staff were helpful, and inspectors observed warm and respectful interactions.
- Responsive?
- Good
- Care was personalised around people's preferences, communication needs and interests. The home provided activities, supported relationships and had a complaints process.
- Well-led?
- Requires improvement
- The manager promoted an open and positive culture, but audits did not reliably identify errors in care plans, risk assessments and capacity assessments. Inspectors recommended seeking advice about effective governance and audits.
What inspectors found, July 2019
Kathleens Lodge Rest Home Ltd was rated Good overall, but inspectors found weaknesses in audits and care records, so well-led was Requires Improvement.
Inspectors made an unannounced visit on 14 June 2019. They spoke with people living in the home, staff, a relative, healthcare professionals and the manager. They also observed care and checked care plans, medicines, staff files and management records.
The overall picture was positive. People said they felt safe and were treated kindly. Inspectors found enough staff, safe medicines handling, suitable training, good access to healthcare, personalised care and a wide range of activities.
The main weakness was in how the home checked its own work. Audits did not always find errors or missing information in care plans, risk assessments and mental capacity assessments. The manager acted on several issues during and after the inspection, but inspectors said the quality assurance system was not robust enough.
The overall rating stayed Good, as did Safe, Effective, Caring and Responsive. Well-led fell from Good at the previous inspection to Requires Improvement.
Kind and respectful care
People and relatives spoke positively about staff. Inspectors saw staff spending time with people and protecting their dignity, privacy and independence.
“People and their relatives were positive about the care and support provided.” from the report
Personalised activities
The home had a dedicated activity coordinator and offered activities based on people's interests, memories and choices. People could also choose not to join group activities.
“A dedicated activity coordinator was in post and people had access to a wide range of activities.” from the report
Good partnership with healthcare services
Staff knew people well and involved healthcare professionals when needed. The home worked with community health teams to support people's health and avoid unnecessary hospital admissions.
“The registered manager and staff team worked in partnership with the local community matron, admission's nurse and community mental health team.” from the report
Audits did not find record errors
needs fixingCare plan audits failed to identify discrepancies and other missing or outdated information. This meant the home's checking system was not consistently driving improvement.
“However, monthly care plan audits failed to pick up discrepancies with documentation.” from the report
Constipation guidance was not initially recorded
needs fixingBowel monitoring charts were not analysed to check whether treatment remained effective, and staff guidance about constipation was not initially available in care plans. Guidance was added during the inspection process.
“Constipation care plans were also not in place providing guidance for staff on the signs and symptoms of constipation.” from the report
- 01How do you now check that care plans and risk assessments contain complete and current information?
- 02How are mental capacity assessments completed so that each specific decision is assessed separately?
- 03How do you monitor bowel records and check that constipation treatment remains effective?
- 04How will you make sure agency staff can find clear guidance about people's individual risks and health needs?
- 05What changes have been made since the inspection to strengthen audits and quality checks?
This was a planned, unannounced inspection covering all five key questions; the previous overall rating and all five previous question ratings were from the inspection published on 21 November 2017. This explanation was written from the published report of 20 July 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, November 2017
Kathleens Lodge Rest Home Ltd is rated Good; inspectors found safe care and respected choices, but identified issues with staff deployment and updating care records.
This was an unannounced focused inspection on 26 October 2017. It followed anonymous concerns about staffing, early rising and personal care routines. One inspector arrived at 6am, spoke with people and staff, observed care and checked records.
The home had 20 people living there. Inspectors found enough staff to meet people's needs safely. People appeared calm and safe, and staff respected individual choices about getting up, personal care, meals and where to spend time.
Inspectors found that risks and medicines were managed safely. They also found some concerns about night staff helping people with personal care before day staff arrived, and one person's care records had not yet been updated after their needs changed. The manager provided evidence of action within 24 hours.
The overall rating was Good, and Safe was rated Good. This was not a full inspection of every area. The other ratings carried over from the previous comprehensive inspection in August 2016, when all areas were rated Good.
Enough staff on duty
Inspectors found staffing levels were sufficient to meet people's needs safely. Dependency assessments were reviewed weekly and agency staff were used only as a last resort.
“Sufficient numbers of staff were deployed to safely meet people's needs.” from the report
Choices were respected
People's preferences about when to get up, go to bed, eat, drink and receive personal care were followed. People could also spend time where they chose.
“Staff understood people's individual needs and preferences and we observed these were respected.” from the report
Calm and safe atmosphere
People appeared comfortable with staff, and inspectors saw staff checking that people were happy. The home was described as calm and relaxed.
“There was a very relaxed and calm atmosphere in the home and it was apparent that people felt safe and at ease in the presence of staff.” from the report
Risks were assessed
The home used risk assessments and safety checks covering areas such as moving and handling, falls and self-neglect. Staff had relevant moving and handling training.
“Risks to people were managed so they were protected and their freedom was supported and respected.” from the report
Medicines were managed safely
The manager changed medicine ordering and collection arrangements after earlier supply problems. Inspectors found no recent incidents of people missing medicines at the required times.
“Since this change there had been no incidents where people did not receive their medicines at the times they required.” from the report
Night staff deployment
seriousThree people needed two staff for personal care. Inspectors found that night staff had regularly supported them before day staff arrived, leaving no staff available to assist other people temporarily. The manager said staff had been told not to do this and arranged a further staff meeting.
“This resulted in no staff being present to assist the remaining people who lived at the home.” from the report
Care records were not updated
needs fixingOne person's needs had increased and required more staff for personal care, but their care records did not yet show the change. The manager sent evidence of a new risk assessment, care plan and monitoring arrangements within 24 hours.
“Despite both staff and the registered manager telling us about the changes in the person's needs the care records for the person did not reflect this.” from the report
- 01How do you make sure night staff are not all occupied with two-person personal care when other people may need help?
- 02How quickly are care plans and risk assessments updated when a person's needs increase?
- 03What happened after the staff meeting arranged to discuss staff deployment and supporting people's care needs?
- 04How are weekly dependency assessments used to decide the number of staff on each shift?
- 05How do you make sure people continue to receive medicines on time if there are problems with the pharmacy or GP?
This was a focused inspection of Safe only, following concerns about staffing and routines; the other ratings carried over from the comprehensive inspection on 19 August 2016, when all areas were rated Good. This explanation was written from the published report of 21 November 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 Kathleens Lodge Rest Home Ltd
3 rated inspections over 3 years: the service has held its Good rating throughout.
- July 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Kathleens Lodge Rest Home Ltd →
- November 2017Goodstayed GoodSafe: Good
Read what inspectors found at Kathleens Lodge Rest Home Ltd →
- September 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2015
Registered with the Care Quality Commission on 27 October 2015.
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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
28 live-in carers within about an hour of West Sussex
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,020 to £1,170 a week. 23 can care for a couple. 11 years' experience on average.
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.