CQC report explained · a residential care home
What the CQC found at Kirby House
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, September 2023
Inspected but not rated; inspectors found outstanding fire-safety work that meant people were not always protected from fire risk.
This was an unannounced, targeted inspection on 24 April 2023. One inspector checked fire safety and followed up concerns raised by the fire and rescue service. They reviewed the building, relevant policies and the provider’s action plan, and spoke with managers.
Some fire-safety improvements had been completed, including emergency lighting and heat detectors in and around the laundry. Staff had received fire-safety information and training, and staffing levels were judged sufficient to support people during a fire.
However, some required work was still outstanding. This included replacing smoke seals on some fire doors, making a fire-door keyhole compliant and installing required automated safety systems. The inspectors said people were not always protected from fire risks.
This inspection was too narrow to give a new rating. The previous overall rating remains Good, from the inspection published in March 2018. The whole Safe question will be assessed at the next comprehensive inspection.
Emergency lighting
The home had installed the required emergency lighting in the areas identified as needing it.
“The provider had installed required emergency lighting in the areas where required.” from the report
Fire-safety checks
Managers and maintenance staff regularly checked fire extinguishers, evacuation pads and related procedures.
“The registered manager and maintenance staff oversaw regular checks of the fire extinguishers, evacuations pads and related protocols.” from the report
Action plan
The provider had a plan to complete the remaining fire-safety actions.
“We were satisfied the provider had an action plan in place to complete the outstanding fire safety actions.” from the report
People not always protected from fire
seriousInspectors found that outstanding fire-safety issues meant people were not always protected from the risk of harm in a fire.
“People were not always protected from fire risks.” from the report
Fire-door work unfinished
needs fixingA required fire door had been installed, but its keyhole still needed further work to meet fire-safety requirements.
“The provider had installed a required fire door, however additional alteration was required to make the keyhole in the door fire compliant.” from the report
Missing safety measures
seriousSome smoke seals had not been replaced and required automated safety systems had not yet been installed.
“Required automated systems to support safety had not been installed.” from the report
- 01Has the keyhole on the fire door now been altered so it is fire compliant?
- 02Have the required smoke seals on all fire doors been replaced?
- 03Have the required automated fire-safety systems now been installed and tested?
- 04Can you show us evidence that the home met the fire and rescue service deadline of 20 September 2023?
- 05How are staff kept competent in fire procedures, and how would the home evacuate residents in an emergency?
This was a targeted inspection of fire safety only; it did not assess the whole Safe question or the other four questions, and the previous overall rating remained Good. This explanation was written from the published report of 1 September 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, March 2018
Rated Good; inspectors found safe, kind and personalised care, with some concerns about call-bell waits and confidence in complaining.
This was an unannounced comprehensive inspection on 29 January 2018, followed by an announced visit on 30 January. Inspectors spoke with people living in the home, relatives and staff. They observed care and checked care records, staff files, training, rotas, complaints and quality checks.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe recruitment, suitable risk assessments and safe medicines arrangements. Staff were trained and supported, and people received help with food, drink and healthcare.
People were treated with kindness and respect. Care plans included personal preferences and were reviewed regularly. The home offered activities, welcomed visitors and had a complaints process. The previous problem of not having a registered manager had been corrected.
Staffing and safety
Inspectors found staff available when people needed support. Recruitment checks and emergency arrangements were also in place.
“We saw that staff were available when people needed them and that they did not have to wait to receive the support they needed.” from the report
Trained staff
Staff received an induction, role-related training, supervision and regular competency checks.
“We saw that staff completed training in topic areas such as health and safety, medicines awareness and dementia.” from the report
Kind and respectful care
Staff knew people well and gave them time to talk. Inspectors saw people being offered choices and treated with dignity.
“Throughout the day we saw staff taking time to talk with people.” from the report
Personalised care
Care plans included people’s preferences, routines, hobbies and life history. Staff used this information to provide consistent care.
“People's care plans were reviewed regularly. This meant staff had up to date information about people's needs.” from the report
Activities and relationships
The home offered group and one-to-one activities and supported people to maintain relationships, faith and personal interests.
“The provider employed two activity people. They offered both group and one to one activities depending on what people expressed interest in.” from the report
Improved leadership
The previous lack of a registered manager had been resolved. The home had quality monitoring systems and an open culture.
“The service now has a registered manager.” from the report
Call-bell response
needs fixingCall bells were usually answered promptly, but one person said staff sometimes switched the bell off and took too long to return. The registered manager said this would be investigated.
“On the whole, I don't have to wait long (when they press the call bell) but I don't really like it when they pop in and switch it off (at the wall) but then take ages to come back.” from the report
Confidence to complain
minorMost people and relatives knew how to complain, but one person worried that making a complaint could make things worse. This is worth discussing with the home.
“I suppose I could complain, but then again it might come back on me and get worse.” from the report
- 01How do you check that call bells are answered promptly, and what did you do after the concern raised during this inspection?
- 02How can my relative make a complaint privately, and how do you make sure they will not experience worse treatment afterwards?
- 03How often will my relative’s care plan be reviewed, and how will our family be involved?
- 04What activities are available for people who prefer one-to-one support or have particular interests?
- 05Has the change from the electronic medicines recording system to paper records been completed safely?
This was a comprehensive inspection covering all five questions: Safe, Effective, Caring, Responsive and Well-led. This explanation was written from the published report of 8 March 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 Kirby House
2 rated inspections over 2 years: the service has held its Good rating throughout.
- September 2023Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- March 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2013
Report published without a new overall rating.
- September 2012
Registered with the Care Quality Commission on 28 September 2012.
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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