CQC report explained · a nursing home
What the CQC found at Kavanagh Place
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, June 2021
Rated Good; inspectors found safe, kind care, but care records and communication were not always reliable.
This was an unannounced inspection on 4 and 12 May 2021. Inspectors first looked at concerns about staffing, leadership and the building. They then widened the visit to examine Safe and Well-led.
The home was rated Good overall, with Good ratings for Safe and Well-led. Inspectors found enough staff, safe recruitment, suitable infection control and kind interactions. Medicines were managed safely, although two recording errors were found and investigated.
Some care records did not clearly show that planned care, including repositioning, had taken place. Parts of the building needed maintenance, although repairs and refurbishment were underway. Some relatives also said communication was not always clear or followed up.
Enough staff
Inspectors found enough suitably qualified staff. Staff were visible and available to help people with care, eating, drinking and activities.
“There were enough suitably qualified staff to support people safely.” from the report
Kind interactions
Staff knew people well and inspectors saw positive interactions. Relatives described care as compassionate and said people felt safe.
“Staff knew the people they supported well and we observed many positive interactions throughout the inspection.” from the report
Medicines managed safely
Medicines were stored, administered and audited safely. The two recording errors found during the inspection were investigated and action was taken.
“The provider completed a thorough review of these concerns during the inspection and took appropriate action.” from the report
Good partnership working
Staff worked with health and social care professionals and made referrals when people needed further advice or support.
“Staff at the home worked with other relevant health and social care professionals to maintain people's health and wellbeing.” from the report
Care records were inconsistent
needs fixingRecords did not always show that care had been delivered in line with people's assessed needs. This included records of regular repositioning, although inspectors found no impact on people's skin condition.
“There were some inconsistencies with the recording of care. It wasn't always clear people's care was being delivered in line with their assessed needs.” from the report
Communication with relatives
needs fixingSome relatives said messages were not always passed to the right people and queries did not always receive a response. They were also not told about management changes.
“Some relatives felt communication with the home could be improved.” from the report
Two medicine recording errors
needs fixingTwo medicine administration records indicated medicines had not been given as prescribed. No harm was caused, and the provider investigated and acted during the inspection.
“There were two instances were the medicine administration records indicated medicines had not been given as prescribed.” from the report
Some maintenance needed
minorSome areas were less well maintained. One bathroom had broken floor tiles, which were replaced before the second inspection day, and refurbishment was underway.
“Some areas of the home were not as well maintained as others, however there was a programme of re-decoration underway at the time of the inspection to address this.” from the report
- 01What changes have been made to ensure care records show that planned care, including repositioning, has taken place?
- 02What checks are now in place after the two medicine recording errors?
- 03Who is currently responsible for managing the home, and has the new manager been registered with the CQC?
- 04How will relatives receive information about management changes and get prompt answers to their queries?
- 05Which refurbishment and maintenance work identified during the inspection has now been completed?
This was a focused inspection of Safe and Well-led after targeted concerns; Effective, Caring and Responsive were not assessed and their previous ratings were carried forward. This explanation was written from the published report of 24 June 2021 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, August 2018
Kavanagh Place rated Good; inspectors found safe, kind and personalised care, with some training and record-keeping issues to improve.
Inspectors visited on 23 and 24 July 2018 without warning. They spoke with people, relatives, staff and managers. They reviewed care records, medicines, recruitment files, policies and complaints. They also observed care, meals and the home environment.
All five areas were rated Good: safe, effective, caring, responsive and well-led. Inspectors found that medicines were now managed safely, staffing levels met people's needs, and risks were assessed and reviewed. The home was clean and staff understood safeguarding procedures.
Staff were described as kind and familiar with people's needs, preferences and routines. Care plans were personalised. People had access to activities and healthcare professionals. The report also identified areas needing further work, including some staff training, making complaints information clearer, and checking that care instructions were always followed.
The previous inspection in June 2017 had rated the service Requires Improvement and found a breach about safe care and treatment, particularly medicines. At this inspection, the provider was complying with all regulations and the overall rating improved to Good.
Medicines improved
Medicines were safely stored, administered and recorded. This addressed the medicines concerns found at the previous inspection.
“During this inspection, we found that the medication management processes had improved.” from the report
Kind, familiar staff
Staff knew people's needs, preferences and routines. Inspectors saw warm interactions and relatives gave positive feedback about dignity and respect.
“We observed interactions between staff and people were warm, kind, and sincere.” from the report
Personalised care
Care records included detailed information about people's daily lives, likes and wishes. Staff supported people to remain as independent as possible while managing risks.
“During this inspection we found that care records contained up to date, consistent and relevant information required for staff to provide 'person centred care' and support.” from the report
Staffing and safety
Inspectors found enough staff to meet people's needs. Recruitment checks, safeguarding arrangements, accident monitoring and emergency plans were in place.
“All four units were sufficiently staffed and people received the level of care and support they required.” from the report
Activities and healthcare
People could take part in a range of activities and receive support from healthcare professionals, including physiotherapy and speech and language therapy.
“There was a variety of different activities available for people to engage in.” from the report
Some care instructions were not followed consistently
needs fixingTwo records did not match the required care. Blood sugar checks were not consistently taken, and one repositioning chart indicated four-hourly rather than two-hourly repositioning. The manager corrected these issues after inspectors raised them.
“We identified two disparities that needed to be addressed with the registered manager.” from the report
Training gaps
needs fixingSome staff training completion rates were below organisational targets. End-of-life training had not improved since the previous inspection.
“We were informed that the training course was available for staff to access but statistics around this area of learning and development had not improved.” from the report
Food support needed checking
seriousDuring an observation, one person who needed food cut into small pieces because of a choking risk did not appear to receive the required support. The manager agreed to investigate.
“Food to be cut up into small bite sized pieces due to choking risk did not appear to receive the support required to effectively manage risk.” from the report
Complaints process not well understood
needs fixingAlthough complaints were handled according to the policy, the most recent survey showed that many people did not know how to complain.
“Only 54 per cent of people living at the home knew how to make a complaint.” from the report
Audit follow-up was unclear
minorAudits were carried out, but records did not always show whether identified actions had been completed. Staff survey results also did not have a linked action plan.
“It was not always clear to see if the actions had been addressed or if they still needed to be actioned.” from the report
- 01How do you now check that blood sugar monitoring and repositioning instructions are followed and recorded correctly?
- 02What training have staff completed in end-of-life care, moving and handling, and person-centred support?
- 03How do you make sure people at risk of choking receive food prepared exactly as their care plan says?
- 04How are people told about the complaints process, and how can someone complain if they cannot do so independently?
- 05How do your audits show that repairs and other improvement actions have been completed?
This was an unannounced comprehensive inspection covering all five key questions, with the previous Requires Improvement rating and medicines breach reassessed. This explanation was written from the published report of 29 August 2018 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 Kavanagh Place
5 rated inspections over 6 years: the service has held its Good rating throughout.
- June 2021Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2018Goodup from Requires improvementSafe: GoodWell-led: Good
- July 2017Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2016Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 12 January 2011.
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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