Kitwood House Care Residence

Updated 3 March 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

Inspection team

This inspection was carried out by 2 inspectors, a specialist advisor and an Expert by Experience on the first day of the inspection and 1 inspector on subsequent days. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service. The specialist advisor was a nurse.

Service and service type

Kitwood House Care Residence is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Kitwood House Care Residence is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

At the time of our inspection there was not a registered manager in post. A new manager had been appointed and had submitted an application to register. We are currently assessing this application.

Notice of inspection

This inspection was unannounced. Inspection activity started on 9 February 2023 and ended on 24 February 2023. We visited service on 9 and 16 February 2023.

What we did before the inspection

We reviewed information we had received about the service since the last inspection and sought feedback from the local authority. We used information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all of this information to plan our inspection.

During the inspection

We spoke with 4 people who used the service and 7 relatives/visitors, 3 by telephone and 4 in person. We also spoke with the manager, deputy manager, nominated individual, regional support manager and 18 members of staff which included the clinical lead, nurses, care staff, head housekeeper, maintenance person, activities co-ordinator and agency staff. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We also contacted 4 external professionals with experience of working with the service.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We reviewed a range of records. This included 7 people’s care records, multiple medication records and 3 staff recruitment files. We reviewed a variety of records relating to the management of the service including policies and procedures. We continued to seek information and clarification from the provider to validate evidence found.

Updated 3 March 2023

About the service

Kitwood House Care Residence is a residential care home, providing personal and nursing care to 60 people at the time of the inspection. The service can support up to 68 people across 4 units and specialises in providing care to people living with dementia. Two of the units provide support for people with complex needs and expressions of emotional distress.

People’s experience of using this service and what we found

Systems and procedures were in place to protect people from abuse. People received their medicines as prescribed, administered by trained and competent staff. During the inspection we observed there were sufficient staff to meet people’s needs. People received support from a consistent and familiar staff team. Safe recruitment procedures were followed, including relevant safety checks. Systems were in place to prevent and control the spread of infection and staff had access to plentiful supplies of personal protective equipment, such as masks, aprons and gloves. At the time of the inspection there were no restrictions in place regarding visiting arrangements.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Staff received training relevant to their role. There was an induction programme for permanent and agency staff. People’s nutritional needs, risks and preferences were assessed and regularly reviewed. We observed the lunchtime experience to be a calm and sociable experience, where staff assisted people who required support with their meal in a warm, friendly and unhurried manner. People spoke positively about the food on offer. People were offered choice and cultural dietary needs were considered and catered for.

Governance systems were in place to assess and monitor the quality of the service. People and staff told us there was a positive culture within the service and felt the service was well-led. The manager demonstrated a clear focus to continually improve the service and to capture learning at every opportunity.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (25 January 2022). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations relating to safeguarding people from harm, safety around medicines and accidents and incidents, staffing, and good governance.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 25 November 2021 and 9 December 2021. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment, safeguarding service users from abuse and improper treatment, staffing and good governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Effective and Well-led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Kitwood House Care Residence on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.