CQC report explained · a residential care home
What the CQC found at Kilkee Lodge Residential Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Good
- Risks to people's health and wellbeing had improved, medicines were managed correctly, and staff knew how to raise safeguarding concerns. Inspectors also found an unpleasant odour downstairs and mixed views about staffing levels.
- Effective?
- Good
- This question was not inspected during this focused visit. Its previous rating was used to calculate the overall rating.
- Caring?
- Good
- This question was not inspected during this focused visit. Its previous rating was used to calculate the overall rating.
- Responsive?
- Good
- Care plans recorded people's needs, choices and preferences. People were supported with activities, communication, family involvement and end-of-life care.
- Well-led?
- Requires improvement
- The management structure was clear and staff described managers as supportive, but audits did not consistently identify or address problems. Complaints and concerns were not always recorded, and the rehabilitation service lacked clear guidance.
What inspectors found, June 2023
Rated Requires Improvement; inspectors found safe, responsive care but weak oversight and a continuing governance breach.
This was an unannounced focused inspection on 20 April 2023. Inspectors spoke with people, relatives and staff, observed care, and checked care plans, medicines records, recruitment files and management records.
The home was rated Good for Safe and Responsive. People received their medicines, risks were generally managed better, staffing arrangements had improved, and people were supported with personalised care, activities and end-of-life care.
The home was rated Requires Improvement for Well-led, so the overall rating was Requires Improvement. Quality checks did not reliably identify problems with hygiene, staff refresher training, risk assessment checks, complaints records or the rehabilitation service. The provider remained in breach of Regulation 17 on good governance.
Better risk management
Inspectors found that risks to people's health and wellbeing had improved. Staff had clearer guidance and safer moving and handling practice.
“Risks to people's health and wellbeing had improved. People's needs were assessed and effectively managed to keep them safe.” from the report
Medicines
People received their medicines as prescribed. Records, storage, dispensing and checks were found to be in order.
“Medicines were ordered, stored and dispensed as required. Medicine administration records (MAR) were viewed, and these were completed correctly.” from the report
Personalised care
Care plans recorded people's choices, preferences and health needs. Staff were said to know people well and support their independence.
“Care plans detailed people's physical, emotional, sensory, and mental health needs.” from the report
Activities and relationships
People could join social and leisure activities, and families were welcomed and involved. Suggestions from meetings had led to new activities.
“The service employed three activity coordinators to provide a programme of support social and leisure activities which people enjoyed.” from the report
Weak quality oversight
seriousAudits had improved but did not consistently identify problems with hygiene, risk assessments, training and complaints. This was the subject of the continuing governance breach.
“Governance processes were not effective as they had not identified or addressed shortfalls.” from the report
Staff refresher training
needs fixingMany staff were not up to date with required refresher training, including safeguarding and medicines knowledge. Risk assessment training was arranged shortly after the inspection.
“The provider's audit system had failed to identify that staff were not up to date with their knowledge and skills.” from the report
Hygiene and bathrooms
needs fixingInspectors found an unpleasant odour downstairs. Two bathrooms needed attention and were not clearly being kept out of use.
“Two of the bathrooms were not fit for purpose. The enamel in the baths was chipped and this was therefore no longer a wipe clean surface.” from the report
Complaints records
needs fixingSome families had raised concerns, but these were not provided to inspectors and were not always recorded properly. This limited the home's ability to learn from complaints.
“The system where comments, complaints and views raised by people and family members was not being managed effectively.” from the report
Rehabilitation guidance
seriousThe home was providing rehabilitation to help people regain independence and return home, but it had no clear policies or procedures for this service. This was also missing from its statement of purpose.
“The service was still providing rehabilitation services, but no policies and procedures had been developed since the last inspection to provide this service.” from the report
- 01What has been done to remove the unpleasant odour downstairs, and how are hygiene checks now recorded?
- 02How have you ensured all staff are up to date with safeguarding, medicines and other refresher training?
- 03How are risk assessments checked for accuracy after staff complete them?
- 04How are complaints and informal concerns from families now recorded and used to make improvements?
- 05What written guidance now covers the rehabilitation service, and how is it reflected in the statement of purpose?
This was an unannounced focused inspection of Safe, Responsive and Well-led; Effective and Caring were not inspected, so previous ratings were used to calculate the overall rating. This explanation was written from the published report of 21 June 2023 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, May 2021
Rated Requires Improvement; inspectors found risks, medicines and oversight were not always managed safely.
This was an unannounced focused inspection after a recent COVID-19 outbreak and other concerns. Inspectors looked mainly at Safe and Well-led. They spoke with people, relatives and staff, observed care, and checked care, medicines, recruitment and management records.
The home was not always keeping people safe. Risk assessments and moving and handling guidance were not detailed enough. A person had been seriously injured after falling from a hoist, and another person at high risk of falls was observed alone with unsafe footwear while an alarm mat was not working.
Medicines were not always handled in line with guidance. Staff signed records before giving medicines, medicines were left unattended, and hand hygiene was inconsistent. Infection control arrangements had some gaps, although testing, personal protective equipment, shielding and social distancing arrangements were found to be in place.
The overall rating fell from Good at the previous inspection to Requires Improvement. Safe and Well-led were both rated Requires Improvement. The report says the provider breached Regulations 12 and 17 and must send CQC a report explaining what action it will take.
Safeguarding processes
There were arrangements for raising and investigating safeguarding concerns. Staff understood what to do if they were worried about abuse.
“There were systems in place to safeguard people from abuse.” from the report
COVID-19 testing
The home had introduced regular testing for staff, including weekly swab testing and regular lateral flow testing. Inspectors were assured that testing could identify some cases without symptoms.
“The manager had implemented a regular COVID-19 testing regime for staff.” from the report
Communication with relatives
Relatives reported being happy with the updates they received during the pandemic. The home had arranged socially distanced visits in several ways.
“Relatives we spoke with were happy with the communication and updates they received during the pandemic.” from the report
Approachable new manager
Staff said the new manager was approachable and had begun making changes. New daily meetings had also been introduced to improve communication.
“Staff told us the new manager was approachable and had started to make some changes at the service.” from the report
Falls and moving risks
seriousRisk assessments did not give staff enough detail about safe transfers. Inspectors also found a non-working alarm mat and observed a person at high risk of falls alone with unsafe footwear.
“Risks to people were not always assessed or effectively managed to keep people safe.” from the report
Medicines practice
seriousStaff sometimes signed medicine records before giving the medicines. Medicines were left unattended and hand hygiene was not always followed.
“Medicines were not consistently well managed.” from the report
Call bell response
needs fixingSome call bells rang for more than ten minutes while people were calling for help to use the bathroom. Inspectors could not see that calls were always monitored effectively.
“Call bells were ringing, some in excess of ten minutes and we could not see that these were always monitored effectively.” from the report
Infection control gaps
needs fixingVisitor screening was not comprehensive or consistently followed. Some areas were cluttered, equipment was not always cleaned after use, and protective equipment was not always stored safely.
“We were not fully assured the provider was preventing visitors from catching and spreading infections.” from the report
Weak quality checks
seriousAudits were not completed consistently and failed to identify several problems. The home did not have a robust action plan with clear responsibilities and timescales.
“There were some audits on quality and safety, but they had not been consistently undertaken and did not demonstrate that quality or safety was being monitored effectively.” from the report
- 01What has changed since the inspection to make moving and handling guidance clear for each person?
- 02How do you now prevent falls, and how do you check that alarm mats and other safety equipment are working?
- 03How are medicines administered and recorded now, including checking that staff give medicines before signing the record?
- 04How quickly are call bells answered, and how do you monitor unanswered calls?
- 05What action plan is in place to address the Regulation 12 and Regulation 17 breaches, and what evidence can you show of completed improvements?
This was an unannounced focused inspection of Safe and Well-led, with infection prevention and control included under Safe; the other question ratings were not given in this report. This explanation was written from the published report of 15 May 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.
Every inspection of Kilkee Lodge Residential Home
6 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- June 2023Requires improvementcurrent ratingstayed Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Kilkee Lodge Residential Home →
- May 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
Read what inspectors found at Kilkee Lodge Residential Home →
- April 2019Goodup from Requires improvementSafe: GoodResponsive: Requires improvementWell-led: Good
- April 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2017Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2014
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 2 December 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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