CQC report explained · a nursing home
What the CQC found at Kitwood House Care Residence
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, March 2023
Kitwood House Care Residence is rated Good; inspectors found safe, effective and well-led care, with improvements since the previous inspection.
This was an unannounced focused inspection. Inspectors visited on 9 and 16 February 2023, spoke with people, relatives, staff and professionals, observed care, and checked care, medicine, recruitment and management records.
The home was rated Good for Safe, Effective and Well-led. Inspectors found medicines were given safely, staffing appeared sufficient, care plans and risks were reviewed, staff were trained, and management systems had improved.
The previous rating was Requires Improvement after inspections in late 2021. The provider had an action plan, and inspectors found it was no longer in breach of the regulations relating to safeguarding, medicines and accidents, staffing, and good governance.
This inspection did not cover Caring or Responsive. The overall Good rating used the ratings from the previous inspection for the questions that were not inspected.
Safe medicines
Trained and checked staff administered medicines safely. Stocks were well managed and people received medicines as prescribed, including when medicines were hidden or given when needed.
“Medicines were administered safely by staff who had received training and had their competency to do so checked.” from the report
Staffing and recruitment
Staffing appeared sufficient during the inspection. The home used a consistent and familiar group of agency staff and followed relevant recruitment checks.
“During the inspection there appeared to be sufficient staff to meet people's needs.” from the report
Staff skills
Staff received role-related training, including extra training to support people experiencing emotional distress. The training records showed 98% overall compliance.
“The training matrix evidenced completed and planned sessions, with an overall compliance level of 98%.” from the report
Mealtimes and nutrition
Inspectors saw calm, sociable mealtimes. Staff supported people patiently and offered choices, including food that met cultural dietary needs.
“Staff assisted people who required support with their meal in a warm, friendly and unhurried manner.” from the report
Learning and oversight
The management team reviewed accidents and incidents, acted to reduce risks and used learning to improve the service.
“Governance and oversight of accidents and incidents were effective.” from the report
Fire drill records
minorFire drill attendance was recorded, but the records did not explain enough about what had happened during the drills. The provider said more detailed records would be completed in future.
“Although attendance was clearly documented, more detail about what had taken place was needed.” from the report
DoLS renewals
needs fixingInspectors reminded the management team to submit renewal applications for DoLS authorisations on time. The manager took immediate action after this was raised.
“We discussed the need to ensure renewal applications were submitted in a timely manner.” from the report
Reliance on agency staff
minorRecruitment was still ongoing and the home continued to rely on agency staff, although inspectors found a consistent and familiar agency team and additional training was provided.
“Although there remained a reliance on agency staff, there was a consistent and familiar group of agency staff who had worked at the service for a considerable time.” from the report
No registered manager in post
needs fixingThere was no registered manager in post during the inspection. A new manager had applied to register, and the application was still being assessed.
“At the time of our inspection there was not a registered manager in post.” from the report
- 01How are you reducing your reliance on agency staff, and how do you make sure agency staff receive the required training and supervision?
- 02What has changed in the way fire drills are recorded since inspectors found that the records lacked detail?
- 03How do you track DoLS renewals and make sure applications are submitted on time?
- 04Who is managing the home while the manager's registration application is being assessed?
- 05What evidence can you show that the improvements from the previous inspection have been maintained?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and the previous ratings for the uninspected questions were used in the overall rating. This explanation was written from the published report of 3 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, January 2022
Rated Requires Improvement; inspectors found kind and responsive care, but people were not always protected from avoidable harm.
This was the home’s first inspection. It was unannounced and took place on 25 November and 9 December 2021. Inspectors spoke with people, relatives and staff, observed care, and checked care, medicine, staff and management records.
The overall rating was Requires Improvement. Safe, Effective and Well-led were also Requires Improvement. Inspectors found repeated safeguarding concerns, medicines problems, heavy reliance on agency staff, and gaps in staff training and management checks.
There were positive findings too. Staff were kind and respectful, activities were available, the dementia-friendly environment was well designed, and infection control was generally managed well. Responsive and Caring were rated Good.
The provider took immediate action during the inspection, including improving training, staffing, medicine checks and oversight of incidents. CQC required an action plan and said it would monitor progress and return for a further inspection.
Kind and dignified care
Inspectors saw staff treating people kindly, protecting their dignity and supporting independence. Relatives also gave consistently positive feedback.
“Staff supported people in a kind and caring way. People had built trusting relationships with staff who supported them.” from the report
Meaningful activities
People had regular opportunities for activities and interests, including flower arranging, board games and dementia-friendly sensory experiences.
“During the inspection we observed staff who supported people to join in recreational activities including flower arranging and playing board games.” from the report
Dementia-friendly environment
The building and its design were intended to help people living with dementia feel oriented and engaged. Inspectors found a high standard of design and hygiene.
“The service was exceptionally designed to meet the needs of people who lived with dementia.” from the report
Generally good infection control
Apart from checking agency workers’ vaccination status, inspectors were assured about testing, PPE, visiting, hygiene and infection outbreak arrangements.
“We were assured that the provider was using PPE effectively and safely.” from the report
Involvement in decisions
Staff followed the Mental Capacity Act principles, and relatives said they were involved in decisions about care and treatment.
“Relatives told us they felt involved in making decisions about the care and treatment people received.” from the report
Repeated safeguarding incidents
seriousPeople were exposed to harm from others experiencing emotional distress, and risks were not always managed well enough to prevent incidents happening again.
“Safety measures were not always in place to protect people from repeated incidents and this placed them at risk of avoidable harm.” from the report
Medicine safety
seriousOne person did not consistently receive hidden medicines safely. Three people had missed medicines because supplies were out of stock, and records and stock control were not reliable.
“We found three people had not received their medicines because they were out of stock.” from the report
Agency staff checks and training
seriousThe home relied heavily on agency workers. Some were deployed before checks of character, skills, competence or induction training had been completed.
“There was a substantial reliance on agency workers who the provider failed to ensure were checked for good character, skills and competence before being deployed.” from the report
Support for complex distress
seriousStaff did not consistently have the training needed to understand and respond to complex emotional distress. Several incidents involved staff being injured.
“We found several incidents when staff had been injured by people they supported.” from the report
COVID vaccination checks
needs fixingOn the first inspection day, the home had not checked that all agency workers had declared their vaccination status. The provider acted immediately to change this.
“On the first day of the inspection we found the provider failed to ensure all agency workers were asked to declare their COVID-19 vaccination status.” from the report
- 01What specific changes have been made to prevent repeated safeguarding incidents and record the lessons learned?
- 02How do you now check agency workers’ character, competence, training and induction before they start a shift?
- 03How do you make sure medicines are in stock, records are complete, and covert medicines are given safely?
- 04What enhanced training and staffing are now provided on the Dementia Plus unit?
- 05What progress has been made with the CQC action plan, and when is the next review or re-inspection expected?
This was an unannounced first inspection covering all five CQC questions, the care provided and premises, and infection prevention and control arrangements. This explanation was written from the published report of 25 January 2022 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 Kitwood House Care Residence
2 rated inspections over a year: the service has improved, from Requires improvement to Good.
- March 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Kitwood House Care Residence →
- January 2022Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
Read what inspectors found at Kitwood House Care Residence →
- August 2021
Registered with the Care Quality Commission on 2 August 2021.
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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