CQC report explained · a residential care home
What the CQC found at Kirklees
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Medicine systems were not reliable. Inspectors found incorrect medicine balances, incomplete records, missing instructions and no system for recording medicine errors.
- Effective?
- Good
- The report does not give a rating for Effective in this inspection.
- Caring?
- Good
- The report does not give a rating for Caring in this inspection. Inspectors observed kind and caring interactions between people and staff.
- Responsive?
- Good
- The report does not give a rating for Responsive in this inspection.
- Well-led?
- Requires improvement
- Quality checks did not reliably identify or resolve problems. Care plans, risk assessments and other records were not consistently robust.
What inspectors found, January 2024
Rated Requires Improvement; inspectors found unsafe medicine systems and weak checks on quality and safety, although people experienced kind care.
The inspection was unannounced and took place from 14 to 18 December 2023. Inspectors spoke with people living at the home, relatives and staff. They reviewed care records, medicine records, staff recruitment files, audits and other records. They also looked around the home and observed care and infection control.
The home was not always safe. Medicine stocks and records did not always match, some medicine instructions and risk assessments were missing, and there was no system to record medicine errors. Risk records were not always accurate or up to date. Inspectors found no evidence that anyone had been harmed, but said people were at increased risk.
The home was also not always well-led. Audits did not identify some of the problems found by inspectors, action plans were not always completed, and records such as care plans and skin monitoring charts were inconsistent. People generally felt safe and staff were kind, knew people well and responded to their needs.
The overall rating was Requires Improvement. Safe and Well-led were both rated Requires Improvement. The previous rating was Good, published on 2 August 2017. The report says the provider must send an improvement plan and that CQC will monitor progress.
Kind, familiar care
Inspectors saw kind and compassionate interactions. Staff knew people well and responded to their needs.
“There was a positive culture within the service. Staff interactions with people were kind and compassionate.” from the report
People felt safe
People told inspectors they felt safe. Staff had safeguarding training and understood how to report concerns.
“People we spoke with told us they felt safe at the service.” from the report
Staffing and recruitment
Recruitment checks were completed and staffing levels were adjusted according to people’s numbers and needs.
“The provider monitored and made sure sufficient staff were deployed to safely support people.” from the report
Health support
People had access to health professionals, including GPs and therapists, to help maintain their health and wellbeing.
“People benefitted from partnership working with other local health professionals.” from the report
Open management
Managers were described as visible and approachable. Staff said they could raise concerns without fear of negative consequences.
“Management were visible, approachable and took a genuine interest in what people, staff, family, and other professionals had to say.” from the report
Medicine safety
seriousMedicine balances and administration records were not always accurate. Missing risk assessments, instructions and incident records meant inspectors could not be assured that medicines were managed safely.
“Systems and processes were not in place to ensure the safe management of medicines.” from the report
Weak quality checks
seriousAudits failed to identify some of the problems found during the inspection. Actions were not always followed up or completed promptly.
“Systems designed to monitor the safety and quality of the service and take action to mitigate risk, were not robust.” from the report
Incomplete risk and care records
needs fixingRisk records, care plans and skin monitoring charts were not consistently accurate or complete. Records did not always show what action staff had taken.
“Documentation including care plans and risk assessments were not robust and provided inconsistent information.” from the report
Best-interest decisions
needs fixingSome capacity assessments and best-interest decisions did not clearly show how people were supported in the least restrictive way. CQC recommended improvement in this area.
“Staff did not always follow the Mental Capacity Act key principles when making best interest decisions.” from the report
Activities and independence
minorSome people said they were bored and wanted more chances to go out. People did not always have clear goals to improve their quality of life and independence.
“However, some people said they were bored and would like more opportunities to go out.” from the report
- 01What has been changed to make sure medicine stocks, administration records and storage temperature records are accurate every day?
- 02How are medicine errors and incidents now recorded, reviewed and used to prevent repetition?
- 03How are audits checked to make sure they identify problems with medicines, care plans, risk assessments and skin monitoring?
- 04How do you make sure best-interest decisions follow the Mental Capacity Act and use the least restrictive option?
- 05What new activities, outings or personal goals are available for people who want more independence or community opportunities?
This inspection rated Safe and Well-led; the report does not give ratings for Effective, Caring or Responsive. This explanation was written from the published report of 13 January 2024 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 2017
Rated Good; inspectors found safe, kind and person-centred care, with all five areas rated Good.
This was an unannounced comprehensive inspection on 28 and 29 June 2017. The inspector spoke with six people living at the home, managers and five staff members. They reviewed two care records, medicines, training, recruitment, staffing, meals, management records and the building.
People told inspectors they felt safe and staff were kind, patient and supportive. Inspectors found suitable recruitment checks, enough staff on duty, relevant risk assessments, safe medicines procedures and clean, well-maintained premises.
Inspectors found that people were involved in their care, had choices about food and activities, and could be supported to live as independently as possible. People had access to healthcare and activities at the home and in the community. The home had a complaints process and systems for checking and improving its quality.
The overall rating was Good, and Safe, Effective, Caring, Responsive and Well-led were all rated Good. The home was also rated Good at the previous inspection in March 2015, so this inspection found that it remained Good.
People felt safe
People told inspectors they felt safe, and risk assessments described how staff should reduce risks when people went out independently.
“I go out a lot on my own. And it's nice to come back to a lovely safe place to live.” from the report
Kind and respectful staff
Staff were seen respecting privacy, supporting independence and responding with patience and kindness.
“The place is relaxed and that is because everyone is so kind and caring towards everyone.” from the report
Personalised support
Care plans recorded individual routines, preferences and support needs. People were involved in agreeing their care and were encouraged to make choices.
“Care plans were person centred and developed around the individual to promote their choices and live an independent life as possible.” from the report
Activities and independence
People were supported to take part in activities at the home and in the community, follow hobbies and go out independently where appropriate.
“There was lots of support for people who lived at Kirklees to follow their interests in the community and go out independently.” from the report
Good management checks
Managers held meetings, considered feedback and completed audits. They acted on identified issues, such as adding cleaning tasks to the written schedule.
“The registered manager had procedures in place to monitor the quality of service provided.” from the report
Inspectors raised no specific concerns in this report.
- 01How will you assess and review my relative's individual risks, especially if they want to go out independently?
- 02How do you adjust staffing if the number of people living here or their care needs change?
- 03How will you support my relative's preferred hobbies, activities and community outings?
- 04How will you involve my relative, family or advocate in agreeing and reviewing the care plan?
- 05How can we raise a complaint, and how will you tell us what action has been taken?
This was an unannounced comprehensive inspection covering the overall quality of the home and all five key questions. This explanation was written from the published report of 1 August 2017 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 Kirklees
3 rated inspections over 9 years: the service has slipped, from Good to Requires improvement.
- January 2024Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2017Goodstayed GoodSafe: GoodWell-led: Good
- April 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: OutstandingWell-led: Good
- February 2014
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 20 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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12 live-in carers within about an hour of North East Lincolnshire
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 £1,350 a week. 10 can care for a couple. 7 years' experience on average.
“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.”
“Martin was more than a carer, he managed the home and became my uncle's best friend, enriching his life during his last few years.”
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.