About the service Kitwood House Care Residence is a residential care home providing personal and nursing care to 21 people at the time of the inspection. The service can support up to 68 people across four 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
People were not always protected from the risk of avoidable harm. Staff did not always have the skills or experience to support people with complex needs and expressions of emotional distress.
When safeguarding incidents occurred the provider did not always ensure lessons were learnt to prevent repeat or further incidents happening.
The provider failed to ensure COVID-19 guidance was consistently followed. We found some agency workers had been deployed without checking they had been vaccinated against COVID-19. During the inspection the provider took action to improve their system for checking agency workers vaccination status. Other aspects of COVID-19 guidance including testing and use of PPE was sufficiently managed.
People were supported by a high number of agency workers because the provider had not been able to recruit sufficient numbers of permanent staff. People did not always receive consistent support and relatives told us they were concerned about the amount of agency staff relied on. The provider did not always ensure agency workers were checked for good character or training before they were deployed.
Medicines were not always effectively managed. We found shortfalls in relation to the management of covert medicines, stock control and record keeping.
The environment was purposely designed to facilitate and improve orientation and quality of life for people who live with dementia. Excellent hygiene standards had been maintained. Regular maintenance checks were undertaken to ensure good housekeeping and equipment safety.
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.
People’s needs, preferences and pastimes were assessed and reviewed on a regular basis. However, the provider had not fully considered their model of care to effectively design and review support for people who lived on the ‘Dementia Plus’ unit. This unit was designed to support people who displayed complex levels of emotional distress. These people required staff with enhanced knowledge and training to support them. During the inspection the provider took action to improve staff training and liaised with external health and social care professionals to improve people’s experiences.
Staff told us they felt supported and listened to by the senior management team. The provider had quality assurances processes in place and a strong senior management team. They showed they had the ability to remedy concerns identified during the inspection processes. The nominated individual transparently shared their route cause analysis of why failures had occurred. They had worked closely with commissioners to improve safety standards.
Staff supported people in a kind and dignified way. People and relatives told us they were happy with the way staff supported them. People had regular access to stimulating and meaningful activities.
For more details, please see the full report which is on the Care Quality Commission website at www.cqc.org.uk
Rating at last inspection
This service was registered with us on 02/08/2021 and this is the first inspection.
Why we inspected
The inspection was prompted in part due to concerns received about safeguarding incidents. A decision was made for us to inspect and examine those risks.
We have found evidence that the provider needs to make improvements. Please see the safe, effective, responsive and well-led sections of this full report.
During and after the inspection the provider took action to mitigate the risks we identified. You can see what action we have asked the provider to take at the end of this full report.
Enforcement
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.
We have identified breaches in relation to safe care and treatment, safeguarding people from harm and abuse, medicines management, staff training and deployment and governance at this inspection.
Please see the action we have told the provider to take at the end of this report.
Follow up
We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.