CQC report explained · a residential care home
What the CQC found at Kirpa Residential Care
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- People were generally protected from abuse and received medicines safely. However, legionella risks were not fully managed, staff training was incomplete for some staff, and recruitment records were not always complete.
- Effective?
- Good
- This question was not inspected during this visit. Its rating was carried over from the last inspection.
- Caring?
- Good
- This question was not inspected during this visit. Its rating was carried over from the last inspection.
- Responsive?
- Good
- This question was not inspected during this visit. Its rating was carried over from the last inspection.
- Well-led?
- Requires improvement
- The manager was approachable and worked with families and other professionals. However, audits, staff supervision and records did not consistently identify or address important shortfalls.
What inspectors found, March 2023
Rated Requires Improvement; inspectors found people were cared for kindly, but risks, recruitment and staff training were not always managed safely.
This was an unannounced inspection on 18 and 23 January 2023. Inspectors spoke with people living in the home, relatives, staff and health professionals. They reviewed care, medicine, recruitment, training and management records.
People and relatives said they felt safe, included and well cared for. Staff were available, knew people well and gave medicines safely. The home was clean, although refurbishment was still taking place.
Inspectors found important gaps. Legionella risks were not fully assessed or controlled. Some staff training was incomplete or out of date, and recruitment records were missing information. Management checks did not always identify these problems.
The overall rating changed from Good to Requires Improvement. Only Safe and Well-led were inspected at this visit. The other three ratings were carried over from the previous inspection.
Kind and reassuring care
People and relatives spoke positively about the care. Inspectors observed good interactions, and people were supported with dignity and consent.
“We did not observe any evidence of poor care during the inspection.” from the report
Enough staff
Inspectors found there were enough staff to meet people's needs and keep them safe. Relatives also said staffing levels were sufficient.
“People were supported by sufficient numbers of staff to meet their needs and keep them safe.” from the report
Medicines managed safely
Medicines were stored, administered and recorded safely. Staff understood people's medicine needs and had appropriate guidance for medicines taken when needed.
“People received their medicines safely and in line with their prescription.” from the report
Positive relationships
People and relatives felt included and able to raise concerns. The manager worked with families, staff and health professionals.
“The feedback from people and their relatives was very positive, all felt safe, well cared for and included within the service.” from the report
Legionella risk
seriousThe home did not have suitable regular checks and flushing arrangements for little-used water outlets. Inspectors could not be assured that the risk had been properly controlled.
“The provider had not taken full account of the risk of legionella, a potentially fatal infection.” from the report
Staff training
seriousSome mandatory training had not been completed or had expired. This included safeguarding, moving and handling, and fire safety.
“Staff training was not always complete or up to date.” from the report
Recruitment records
seriousSome staff files did not show satisfactory evidence of previous employment conduct, and all the files reviewed had gaps in employment history.
“However, not all staff had satisfactory evidence of conduct in previous employment in health or social care, with children or vulnerable adults.” from the report
Management checks and supervision
needs fixingSome audits had not been completed, staff files had not been audited recently, and supervision was not regular for all staff. Accident records were also not always completed consistently.
“Records showed staff supervisions were not happening regularly for all staff.” from the report
Fire safety records
needs fixingA fire risk assessment was available, but it was not always clear which actions had been completed. Inspectors could not check every action.
“A fire risk assessment was completed in November 2021, but it was not always clear which actions from this had been completed.” from the report
- 01What regular legionella checks and water outlet flushing are now being carried out, and can I see the records?
- 02Has all mandatory staff training, including safeguarding, moving and handling, and fire safety, been completed and kept up to date?
- 03Have all staff files been updated with full employment histories and satisfactory evidence of previous conduct?
- 04How often are staff now receiving supervision or one-to-one meetings?
- 05Which actions from the fire risk assessment and refurbishment plan remain outstanding?
This was an unannounced focused inspection of Safe and Well-led; Effective, Caring and Responsive were not inspected and their ratings carried over from the previous inspection. This explanation was written from the published report of 16 March 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 2019
Haven Rose Residential Care Home was rated Good in all five areas; inspectors found safe, kind and personalised care.
This was an unannounced inspection over two days. The inspector met everyone living at the home, spoke with eight people, reviewed care records and staff records, and received feedback from a health professional.
The home supported up to 16 people with dementia or enduring mental health needs. There were 14 people living there. Inspectors found enough staff, safe medicines practice, suitable training, personalised care plans and good support with health and diet.
People described staff as kind and respectful. They were supported to make choices, maintain independence and take part in the local community. The home had regular meetings, feedback surveys and checks on the quality of care.
All five CQC areas were rated Good. The home was last inspected in August 2016 and was also rated Good.
Safe medicines
Medicines were stored, given and disposed of safely. Staff had medicines training and their knowledge and competence were checked.
“Medicines were stored, administered and disposed of safely. People's medication records confirmed they received their medicines as required.” from the report
Kind and respectful care
People spoke positively about the care. Staff knew people well and respected their privacy, dignity and independence.
“People were supported and treated with dignity and respect; and involved as partners in their care.” from the report
Community involvement
People were encouraged to stay active and take part in activities outside the home. Inspectors saw people interacting with others and going out.
“On both days of the inspection people were interacting with each other, going out into the community or involved with the staff .” from the report
Good oversight
The manager and provider used audits, surveys and a development plan to monitor the service and identify improvements.
“Effective systems were in place to monitor the quality of the service and the care provided.” from the report
Environmental safety checks
needs fixingSome radiators were uncovered and some hot water outlets needed checking. The manager took action and the environment was safe by the end of the inspection.
“On the first day of the inspection we identified some areas for improvement. For example, some radiators were not covered and could pose a risk of people getting burnt.” from the report
Care plan wording
minorInspectors said some decisions in care plans could be described more clearly to show the agreements made with people. They found that decisions were not being imposed on people.
“We discussed how some decisions could be worded better in care planning to reflect the agreements made with people and that decisions were not being imposed on people.” from the report
- 01How do you check that radiators remain covered and that hot water temperatures stay within safe limits?
- 02How are care plans written and reviewed to show people's choices and agreed decisions clearly?
- 03How would you support my relative to take part in local activities and go out safely?
- 04How do you make sure staff have the training and supervision needed for people living with dementia or enduring mental health needs?
- 05How are residents and relatives involved in decisions about routines, activities and menus?
This was an unannounced planned inspection of the whole care home, including the premises and care provided, and it assessed all five CQC questions. This explanation was written from the published report of 10 May 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.
Every inspection of Kirpa Residential Care
4 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- March 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2019Goodstayed GoodSafe: GoodWell-led: Good
- August 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2014
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 30 November 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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