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Kilsby House Residential Home Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 6 March 2021

About the service

Kilsby House Residential Home is a residential care home providing personal care to older people living with dementia. At the time of the inspection 24 people were using the service. The service can support up to 39 people.

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

Systems and processes were not robust enough to identify and monitor the issues we found during the inspection.

Risk assessments were not always completed with the strategies needed to mitigate the known risks.

Records of care tasks were not always completed fully. For example, we found gap in the recording of pressure damage and food and fluid charts.

On the first day of inspection we found concerns with infection control and the management of COVID-19, however by the second day of inspection the provider had made improvements.

People were supported by enough staff who knew them well and had been safety recruited.

Staff and relatives knew the registered manager and felt comfortable raising any concerns with them.

The registered manager and staff were open and transparent throughout the inspection. The registered manager implemented changes immediately after inspection. The provider needs to ensure these changes are embedded into the service.

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

Rating at last inspection

The last rating for this service was good (published 12 April 2019)

Why we inspected

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 coronavirus and other infection outbreaks effectively.

We received concerns in relation to infection control. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.

You can see what action we have asked the provider to take at the end of this full report.

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

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 monitor the service.

We have identified breaches in relation to infection control, safe care and oversight 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 from 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.

Inspection areas

Safe

Requires improvement

Updated 6 March 2021

The service was not always safe.

Details are in our safe findings below.

Effective

Good

Updated 6 March 2021

Caring

Good

Updated 6 March 2021

Responsive

Good

Updated 6 March 2021

Well-led

Requires improvement

Updated 6 March 2021

The service was not always well led.

Details are in our well led findings below.