CQC report explained · a residential care home
What the CQC found at Kirkside House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Risk assessments were detailed, medicines were generally managed safely, staffing levels met people's needs, and infection control arrangements were in place.
- Effective?
- Good
- This key question was not inspected during this focused visit. A rating from an earlier comprehensive inspection was used.
- Caring?
- Good
- This key question was not inspected during this focused visit. A rating from an earlier comprehensive inspection was used.
- Responsive?
- Good
- This key question was not inspected during this focused visit. A rating from an earlier comprehensive inspection was used.
- Well-led?
- Good
- Managers understood their responsibilities, quality checks were used, people and relatives were involved, and the home worked with health professionals.
What inspectors found, January 2021
Rated Good; inspectors found safe, person-centred care and effective management, with a few records and maintenance issues to address.
This was a focused inspection after CQC received concerns about safeguarding, whistleblowing and a possible closed culture. Inspectors visited on four dates, spoke with people, a relative, a health professional, managers and staff, and checked care records, medicines, recruitment files and quality checks.
The home was rated Good overall, with Safe and Well-led also rated Good. Inspectors found people were protected from harm, medicines were generally managed safely, staffing levels met people's needs, and risks were assessed in detail. People and relatives said they felt safe and received good care.
Inspectors found some areas to improve. Thirteen percent of staff needed to update safeguarding training, two as-required medicine protocols had not been reviewed by medical professionals for over a year, and some parts of the building were worn. The other three key questions were not inspected during this visit, so earlier ratings were used for the overall rating.
Detailed risk planning
Risk assessments and positive behaviour support plans were tailored to individuals. They gave staff clear guidance on reducing risks and supporting people's important interests.
“Risk assessments were bespoke and detailed how people should be supported safely.” from the report
Safe medicines practice
Inspectors found that medicines were stored, administered and recorded correctly. As-required medicines were available with guidance for staff.
“Medicines were managed safely. People received their medicines as prescribed and regular audits were carried out to monitor for any inaccuracies.” from the report
Enough suitable staff
People and staff said there were enough staff, and inspectors saw that staff responded promptly. Recruitment checks were in place.
“The provider had robust recruitment checks in place to ensure staff were suitable to work in the home.” from the report
Open management
The management team used audits and an action plan to track improvements. People, relatives and health professionals were kept involved and informed.
“Audits were carried out which provided oversight of improvements required and where actions were needed.” from the report
Respectful, person-centred support
Inspectors found that staff understood people's individual needs and rights. The home followed the principles of choice, dignity, independence and inclusion.
“The service was able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture.” from the report
Safeguarding training overdue
needs fixingThirteen percent of staff needed to update their safeguarding training. The report says some were new or had been off work.
“However, we found 13 percent of staff needed to update their training.” from the report
Medicine protocols needed review
needs fixingTwo protocols for as-required medicines had not been reviewed by medical professionals for more than a year. The manager agreed to update them immediately.
“Two protocols for 'as required' medicines had not been reviewed by medical professionals in over a year.” from the report
Worn areas of the building
minorThe home was mainly clean, but inspectors saw some worn areas that needed refurbishment. The provider had recorded the work in an action plan, but COVID-19 had delayed it.
“The environment was mainly clean however, we noticed some areas of the home were worn and required refurbishment.” from the report
- 01Have the two as-required medicine protocols now been reviewed by medical professionals, and how do you check they stay current?
- 02Has all safeguarding training been brought up to date, including for new staff and staff returning from leave?
- 03Which worn areas of the home have been refurbished since the inspection, and what work remains?
- 04What changes were made in response to the safeguarding and whistleblowing concerns that led to this focused inspection?
- 05How are people and relatives involved in reviewing care, changes and complaints?
This was a focused inspection of Safe and Well-led only; the other three key-question ratings were carried over from the previous comprehensive inspection. This explanation was written from the published report of 23 January 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, March 2020
Rated Good; inspectors found safe, kind and person-centred care, with some records and furnishings needing improvement.
This was an unannounced inspection on 5 and 11 February 2020. One inspector spoke with four people, an advocate, staff, managers and two relatives. The inspector reviewed care, medicines, recruitment, incident, training and quality records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines systems, personalised support plans, kind care and activities that helped people develop skills and stay involved in their community.
There were some shortfalls. Records for one person's crushed medicine were not available during the inspection. Some daily notes did not fully record people's activities, and some furniture was unclean or worn. The home had acted, or agreed to act, on these issues.
The previous inspection had rated the service Requires Improvement and found a breach about reporting incidents to the CQC. At this inspection, inspectors found enough improvement and said the home was no longer in breach.
Developing independence
Support was focused on helping people gain skills, make choices and become more independent.
“People's support focused on them having as many opportunities as possible for them to gain new skills and become more independent.” from the report
Kind and respectful care
People and relatives spoke positively about staff. Inspectors saw supportive relationships and respectful care.
“Staff treated people with kindness and respect. One person said, "I am happy here most of the time and with most of the staff.” from the report
Meaningful activities
People took part in activities linked to their interests, including community activities and social groups.
“One person said, "I like to keep busy, I have plenty to do.” from the report
Strong management checks
The management team used quality checks and audits to monitor safety and improve the service.
“The provider had robust quality assurance systems in place to monitor the quality of the service.” from the report
Crushed medicine records
needs fixingThe records showing that it was safe for one person's medicine to be crushed were not available during the inspection. The manager arranged immediate action to correct this.
“One person received their medicines in a crushed format. The records confirming this was safe were not available at the time of the inspection.” from the report
Gaps in daily notes
needs fixingSome daily notes did not fully show how people had spent their day or whether planned activities had taken place. Managers had already identified this and were working with staff to improve the records.
“Some people's daily notes had gaps. They did not record in full, how people had spent their day or whether they had been engaged in activity as recommended in their positive behaviour support plan.” from the report
Furniture condition
minorThe environment was generally clean, but several pieces of furniture looked unclean or worn. The manager arranged for replacements.
“However, several pieces of furniture looked unclean or worn. The registered manager arranged replacement of these.” from the report
Some records lacked detail
needs fixingThe reasons for some low-stimulus environments had not been fully recorded. The manager agreed to review and improve these records.
“Some people had low stimulus environments to meet their specific needs regarding autism and anxiety. The reasons for this had not been fully recorded.” from the report
Listening to concerns
needs fixingOne person said there were times when they did not feel believed when raising issues. The manager planned further discussion with them.
“However, they said there were times when they didn't always feel believed when raising issues.” from the report
- 01What records now confirm that it is safe to crush any medicines a person needs?
- 02How do you check that daily notes fully record people's activities and engagement?
- 03Have the unclean or worn pieces of furniture all been replaced?
- 04How do you record the reasons for using low-stimulus environments?
- 05How do people raise concerns if they feel they are not being believed or listened to?
This was a planned inspection based on the previous rating and covered all five key questions, with the previous Requires Improvement rating and breach reviewed. This explanation was written from the published report of 4 March 2020 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 Kirkside House
5 rated inspections over 6 years: the service has improved, from Requires improvement to Good.
- January 2021Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2020Goodup from Requires improvementSafe: GoodWell-led: Good
- November 2019Requires improvementdown from GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- May 2014
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.
- September 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 30 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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