CQC report explained · a residential care home
What the CQC found at Kirkella Mansions Residential Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, October 2019
Rated Requires Improvement; inspectors found kind care but unsafe medicines, weak risk controls and poor oversight.
This was an unannounced inspection over two days. Inspectors spoke with people, relatives, staff and health professionals. They observed care and checked care plans, medicine records, staff files and management records.
The home was rated Requires Improvement overall. Safe, responsive and well-led were also Requires Improvement. Effective and caring were rated Good. People said they felt safe, staff were kind, and there were enough staff to meet people's needs.
Inspectors found that medicines were not always given or recorded safely. Risk assessments and accident records were not always reliable. Management checks had not found these problems. Infection control and fire safety had improved since the previous inspection, but the home had not made enough overall improvement.
Kind and respectful staff
People and relatives gave positive feedback about the staff. Inspectors saw that staff knew people well, respected them and supported their choices.
“The staff are fantastic here" and "The staff are very caring.” from the report
Healthcare support
People were supported to access health and social care professionals. Health professionals said staff acted quickly and followed advice.
“The staff are very efficient, they always organise appointments quickly when needed and follow any advice given.” from the report
Food and nutrition
People were offered a choice of food and were supported to eat and drink enough. People who were underweight had support and had gained weight.
“People were supported to eat and drink enough. We observed staff providing people with refreshments throughout the day, including ice lollies during the hot weather.” from the report
Clean environment and staffing
The home was clean and tidy, and inspectors found enough staff to meet people's needs. Improvements had also been made to infection control and fire safety.
“The service was clean and tidy throughout and skirting boards had been replaced.” from the report
Medicines were not always safe
seriousInspectors could not be sure that people always received medicines as prescribed. Records were not accurate or up to date, and some medicines created a risk of overdose.
“People did not always get their medication as prescribed and people were at risk of overdose as timed medication contained no details of when it was administered.” from the report
Risks were not always controlled
seriousRisk assessments were missing or ineffective in some cases. Inspectors found an example where a sensor mat was not plugged in, so staff were not alerted to a fall.
“Their risk assessment stated a sensor mat was in place, but on at least one occasion staff were not alerted to their fall as the mat was not plugged in.” from the report
Management checks did not find problems
seriousQuality systems had been introduced but were not strong enough to identify and correct the shortfalls. Accident reports, care plans and capacity assessments were not always properly recorded.
“Governance systems had been implemented since the last inspection, however they had failed to identify some of the areas we identified at this inspection.” from the report
Limited activities
needs fixingThere was no structured activity programme. The activities coordinator had reduced their hours, leaving people with limited activities.
“There was no structured activity programme in place.” from the report
End of life plan lacked detail
needs fixingOne person who had recently started receiving end of life care did not yet have a detailed care plan. The manager was completing it during the inspection.
“One person had recently started receiving end of life care and there was no detailed care plan in place.” from the report
- 01What has changed since the inspection to make sure every medicine is given as prescribed and recorded accurately?
- 02How are staff's medicine administration skills checked, and how are controlled medicines checked by two staff members?
- 03How do you now identify and manage risks such as falls, and how do you check that equipment such as sensor mats is working?
- 04What structured activities are now available, and how are they matched to each person's interests and needs?
- 05How are care plans, accident records and mental capacity assessments now checked for completeness and accuracy?
This was an unannounced planned inspection covering all five questions, including the premises and the care provided; it followed the previous Requires Improvement rating. This explanation was written from the published report of 10 October 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, September 2018
Rated Requires Improvement; inspectors found kind, effective care but concerns about medicines, fire safety, records and quality checks.
This was an unannounced inspection on 23 July and 2 August 2018. Inspectors spoke with people living in the home, relatives and staff. They observed care and reviewed care plans, risk assessments, medicines records, staff files and management records.
The home was rated Good for effective and caring. Staff understood people's needs, treated them kindly, supported their independence and helped with food, drink and healthcare. Activities were regular and included entertainment, exercises and trips outside the home.
The home was rated Requires Improvement overall, and also for safe, responsive and well-led. Medicines were not always given or recorded as prescribed. Inspectors also found fire safety and infection control issues, care plans without enough detail, and checks that had not found some of these problems.
Some progress had been made since June 2017. Staff training, recruitment checks, inductions, supervision and safeguarding arrangements had improved. However, this was the second consecutive inspection rated Requires Improvement, with breaches of regulations still found.
Kind and respectful care
Inspectors saw staff build warm relationships, respect people's wishes and support their privacy, dignity and independence.
“Staff were kind and caring towards people. Staff had a good understanding of how to respect people's privacy and dignity whilst promoting their independence.” from the report
Support with food and health
Staff supported people to eat and drink, monitored nutrition and involved health professionals when extra help was needed.
“We observed staff supporting people to eat and drink throughout the inspection.” from the report
Regular activities
People had regular activities and one-to-one contact, including music, games, reminiscence, exercise and trips outside the home.
“Activities were well organised and included entertainment, exercises and various trips outside the home.” from the report
Improved staff support
Since the previous inspection, staff training, recruitment checks, induction, supervision and appraisals had improved.
“New staff received a thorough induction and records showed regular competency checks, supervisions and annual appraisals had been completed.” from the report
Medicines were not reliably managed
seriousSome medicines were given at the wrong times, while records were blank, inaccurate or incomplete. Staff did not always seek advice before changing how medicines were given.
“Medicines were not always administered as prescribed, recorded or stored appropriately.” from the report
Fire safety defects
seriousTwo fire doors could not close properly. Inspectors said this could put people at risk by allowing smoke, fumes and fire to spread.
“This meant that people would not be safe in the event of a fire occurring as some fire doors would not close to prevent the spread of smoke, fumes and fire.” from the report
Care plans lacked important detail
needs fixingSome records did not explain people's specific health conditions, skin risks or the support staff should provide. Inspectors suggested seeking guidance and updating the records.
“Records in relation to people's health and well-being did not always include information about people's specific health conditions or guidance for staff on how to manage associated risks.” from the report
Checks did not find problems
needs fixingThe home's audits had not identified several issues found by inspectors, including problems with infection control and fire doors.
“The provider completed a range of audits however these had not identified a number of the issues and concerns we found at this inspection.” from the report
- 01What action has been taken to make sure every medicine is available, given at the prescribed time and recorded accurately?
- 02Have the two fire doors been repaired so they close properly, and when was this work completed?
- 03How are infection control, maintenance and fire safety checks now carried out, and how is completion of actions checked?
- 04How have care plans been updated to give staff clear instructions about each person's health conditions, skin risks and related support?
- 05What improvements have been made since the inspection to prevent a second consecutive Requires Improvement rating?
This was an unannounced inspection covering all five key questions, with the home, care provided, records, medicines, staffing and management systems reviewed. This explanation was written from the published report of 21 September 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 Kirkella Mansions Residential Home
4 rated inspections over 4 years: the service has slipped, from Good to Requires improvement.
- October 2019Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
Read what inspectors found at Kirkella Mansions Residential Home →
- September 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
Read what inspectors found at Kirkella Mansions Residential Home →
- August 2017Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2015GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- November 2013
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- January 2012
Registered with the Care Quality Commission on 26 January 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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16 live-in carers within about an hour of East Riding of Yorkshire
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 £1,030 to £1,420 a week. 14 can care for a couple. 7 years' experience on average.
“She was always 'just present enough': attentive, available, kind and engaging, but without ever over-stepping any boundary”
“What truly stands out is how mindful and attentive she is to all of my medical needs, always going above and beyond to ensure I’m comfortable and well cared for.”
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.