CQC report explained · a residential care home
What the CQC found at Kellan Lodge
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Risk assessments lacked clear detail, infection control training was missing for some staff, and COVID-19 procedures were not fully followed.
- Effective?
- Requires improvement
- Staff had not received specialist training for people's specific health needs, and infection control training was outdated.
- Caring?
- Good
- Staff were caring and respectful, and people appeared happy and comfortable with them.
- Responsive?
- Requires improvement
- Activities were not personalised and did not always promote choice or independence; people were sometimes refused outings without considering their wellbeing.
- Well-led?
- Requires improvement
- Management oversight was ineffective, audits did not identify key issues, and policies were not updated to current guidance.
What inspectors found, February 2021
Rated Requires Improvement; inspectors found caring staff but concerns about risk assessments, infection control, personalised activities, and management oversight.
Inspectors visited Kellan Lodge in December 2020 and January 2021 to check the quality and safety of care. They spoke with people living there, relatives, and staff, and reviewed care records and policies.
They found staff were kind and respectful, and people knew them well. Medicines were given safely and people had enough to eat and drink. However, risk assessments were not detailed enough, and infection control training and procedures were lacking, especially during the COVID-19 pandemic.
People were not always supported to have stimulating activities or to go out as they wished. The management did not spot these problems through their checks and audits. Staff training was not always suitable for people's specific needs.
Because of these issues, the overall rating dropped from Good to Requires Improvement. The inspectors made recommendations and asked the provider to improve risk assessments, infection control, staff training, and personalised care.
Caring staff
People were supported by staff who were caring and respectful in their approach.
“Throughout the inspection we observed that people were supported by staff who were caring and respectful in their approach.” from the report
Safe medicines management
People received their medicines safely and as prescribed, with secure storage and regular audits.
“People received their medicines safely and as prescribed.” from the report
Support with diet
People were supported to eat and drink well, with choices and help to prepare meals if wanted.
“People were supported to eat and drink well to maintain a healthy and balanced diet.” from the report
Staff understand safeguarding
Staff knew how to keep people safe from abuse and had received training in safeguarding.
“Staff understood safeguarding and how to keep people safe from abuse.” from the report
People involved in care planning
Relatives were involved in care planning and reviews, and care plans were person centred.
“Relatives told us that they were involved in the care planning and review process.” from the report
Incomplete risk assessments
seriousRisk assessments did not always provide clear and detailed guidance, missing important information about people's needs.
“Risk assessments did not always provide clear and detailed guidance about people's risks and in some cases significant information had been missed.” from the report
Poor infection control training and procedures
seriousMany staff had not received recent infection control training and COVID-19 guidance was not fully implemented.
“Five staff members out of eight had not received any infection control training since 2019.” from the report
Lack of personalised activities
needs fixingActivities were not tailored to people's interests and did not promote choice or independence, limiting stimulation and community access.
“Activities provision was not person centred and did not taken into consideration people's likes, hobbies and interests.” from the report
Weak management oversight
seriousChecks and audits did not identify key issues, and policies were outdated, risking poor care quality and safety.
“Systems and processes in place to monitor and oversee the quality of care people received were not always effective.” from the report
Staff training gaps
seriousStaff lacked specialist training for people's specific health needs, risking ineffective care.
“Staff did not always have access to the appropriate training to support people effectively and in response to their specific health and care needs.” from the report
- 01What changes have you made to risk assessments since the inspection to ensure they are detailed and up to date?
- 02How have you improved infection control training and procedures, especially related to COVID-19?
- 03What personalised activities and community access do you now provide to support choice and independence?
- 04How do you ensure management oversight identifies and addresses issues promptly?
- 05What specialist training do staff receive to meet the specific health needs of people living here?
This was a focused inspection covering Safe, Effective, Responsive and Well-led; other ratings carried over from 2018. This explanation was written from the published report of 12 February 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, February 2018
Kellan Lodge was rated Good; inspectors found safe, kind and personalised care, with some records needing more formal completion.
The inspection was unannounced and took place on 4 January 2018. One inspector spoke with people living at the home, relatives, care staff and managers. They observed care and checked care records, medicines records, staff files, training records and quality checks.
Inspectors found that people appeared happy, comfortable and at ease. Staff understood safeguarding, staffing levels were sufficient, medicines were managed safely, and care plans included detailed risk assessments. People received support suited to their needs, choices and communication methods.
The home was rated Good in all five areas: safe, effective, caring, responsive and well-led. It remained Good compared with the previous inspection on 24 August 2015.
Kind and respectful care
Inspectors saw positive relationships between people and staff, with support for privacy, dignity and independence.
“Throughout the inspection we saw that people were treated with respect, kindness and compassion.” from the report
Personalised communication
Staff used people's preferred ways of communicating to help them make choices, including non-verbal communication and Makaton.
“During the inspection we observed care staff using these techniques enabling the person to make certain decisions about their care and support.” from the report
Staff training and support
Staff received a thorough induction, ongoing training, supervision and appraisal.
“The provider ensured that all care staff received an in-depth induction and training as well as on-going training, development and support to effectively deliver in their role.” from the report
Good management communication
Relatives and staff said managers were approachable, listened to them and kept in contact.
“Relatives also confirmed that they knew the registered manager and the senior management team who were approachable and available at any time.” from the report
Consent records
needs fixingRelatives had given consent to care, but this had not always been formally recorded in the care plans.
“Relatives confirmed that they had consented to care on behalf of the person however, the service had not formally recorded this.” from the report
Management checks not always recorded
minorSome spot checks and provider visits were not formally recorded, even though the manager said issues found during visits were dealt with.
“The registered manager confirmed that not all spot checks and provider visits had been recorded formally and that because they visited on a regular basis, any identified issues during their visit was addressed immediately.” from the report
- 01How are relatives' consent and best-interest decisions recorded now?
- 02How do you make sure all spot checks and provider visits are formally recorded?
- 03How are changes in a person's communication, health or risks reflected in their care plan?
- 04How do you make sure staffing levels change when people have appointments or different daily activities?
- 05How can relatives raise a concern, and how will they be kept informed about the response?
This was an unannounced inspection covering all five quality areas, with checks of care records, staff records, medicines and management records. This explanation was written from the published report of 15 February 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 Kellan Lodge
3 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- February 2021Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2018Goodstayed GoodSafe: GoodEffective: GoodResponsive: GoodWell-led: Good
- October 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- May 2011
Registered with the Care Quality Commission on 13 May 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.
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
At least 100 live-in carers within about an hour of Enfield
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 £980 to £1,260 a week. 79 can care for a couple. 11 years' experience on average.
“Over the time he spent with them he got to know our parents very well and became like part of the family, even joining in family celebrations.”
“Charity would take Nan on holidays day trips and shopping adventures”
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.