Background to this inspection
Updated
14 November 2017
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.
This inspection took place 2 October 2017 and was carried out by three adult social care inspectors. The inspection was prompted in part by notification of two incidents following which two people using the service sustained an injury. These incidents were reviewed by the CQC, separately to this inspection and it was decided that no further action was necessary. However, the information shared with CQC about the incidents led us to ensure a focus on the management of falls risks and moving and handling during the inspection.
Before the inspection we reviewed the information we held about the service. This included notifications from the provider and speaking with the local authority contracts and safeguarding teams.
We spent time observing care in the lounges and dining rooms. We looked around the building which included all of the bedrooms, bathrooms and communal areas. We also spent time looking at records, which included four people’s care records, four staff recruitment records and records relating to the management of the service. We spoke with six people who used the service, five relatives, seven care workers, the cook, the deputy manager and the home manager. We also spoke with three health care professionals who work with the service.
Updated
14 November 2017
Glen Rosa and Kitwood House provide accommodation and personal care to a maximum of 47 older people in single en-suite rooms. Glen Rosa provides accommodation and personal care for up to 33 older people. Kitwood House is a purpose built specialist unit attached to the main building, which provides care for up to 14 older people living with dementia. The service is located close to Ilkley town centre. We inspected the service on the 2 October 2017. On the day of the inspection 46 people were living in the home.
At the last inspection in July 2015 we rated the service ‘good’ overall and in each individual domain.
At this inspection overall we found the service had maintained the rating of ‘good.’ People and relatives were happy with the care provided and we saw some good examples of high quality care and support. However we rated the ‘Is the service safe?’ domain as ‘Requires Improvement.’ This was due to staffing levels not always being consistently maintained. However we did not identify any significant impact on people as a result of this. The management team had already identified this and we were felt assured this would be addressed through the management plans in place.
A registered manager was not in place, although steps were being taken to address this. The registered manager left in August 2017 and a new manager was now in post who had applying to be the registered manager for the service. This was being assessed by our registration department. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.’
People and relatives spoke positively about the care that was provided by the home. They said staff were appropriately trained, treated them well and told us the management team were effective in their role.
Medicines were safely managed. People received their medicines as prescribed and clear records were kept.
People said they felt safe. Risks to people’s health and safety were assessed and plans of care created for staff to follow. Learning had taken place following incidents to help improve the safety of the service.
The premises was safely managed and suitable for its purpose as a care home. Adaptions had been made to Kitwood House to ensure a suitable environment for people living with dementia.
People and relatives said there were usually enough staff in the home. However staffing levels were not always consistently maintained on both day and night shifts. We saw the service was in the process of over-recruiting to positions to reduce the likelihood this would continue.
Safe recruitment procedures were in place to ensure staff were of suitable character to work with vulnerable people.
Staff received a range of training which was relevant to their role. Staff said they felt well supported by management and received supervision and appraisal.
People praised the choice and variety of food available to them. Where people were at nutritional risk, measures were put in place to help protect them from harm.
The service was acting within the legal framework of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards. Where people lacked capacity to make decisions, best interest processes had been followed in line with the Act.
The service worked closely with a range of health professionals to ensure healthcare needs were met. Health professionals spoke positively about the service.
Staff knew people well and treated people with kindness and compassion. Information on people’s lives and their current preferences had been sought to aid in the provision of personalised care.
People felt listened to and staff offered them choices on a daily basis.
People’s needs were assessed and used to produce appropriate plans of care which we saw were followed by staff. People and relatives said the quality of care was good and met individual needs.
An activities co-ordinator was employed who provided a range of person centred activities. People praised the choice of activities on offer.
Staff said morale was good and that they felt able to approach the management team. People and relatives said the management were helpful and listened to them.
A range of audits and checks were undertaken and we saw management were committed to continuous improvement of the service. People’s feedback was regularly sought and used to make improvements to the service.