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Kirkella Mansions Residential Home Requires improvement


Inspection carried out on 27 August 2019

During a routine inspection

About the service

Kirkella Mansion is a residential care home providing personal and nursing care to people aged 65 and over and people living with dementia. The service can support up to 40 people. At the time of inspection 24 people were using the service.

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

At the last inspection we found concerns regarding medication management, risk management, infection control, fire safety and good governance. Although some improvements were seen at this inspection we had continued concerns with regards to medication, risk management and good governance.

Medication was not managed safely, we could not be assured people received their medication as prescribed and risks to people were not always mitigated. Accident and incidents were not recorded correctly or monitored effectively so lessons could not be learnt.

Governance systems in place had failed to make the required improvements. Quality monitoring and governance systems had been implemented but were not robust. They had not identified some of the shortfalls identified at this inspection.

People told us they felt safe. There was adequate staff to meet people’s needs. The service was clean, and staff had knowledge of how to prevent the risk of spread of infection.

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 supported people with their health care needs and we received positive feedback from health professionals.

Staff were kind and caring and treated people with respect.

We observed limited activities on offer during the inspection. We made a recommendation regarding the provision of activities. People were happy with the care they received and told us care was delivered in line with their preferences.

People and staff were positive about the management team and the support they received.

For more details, please see the full report which is on the Care Quality Commission (CQC) website at

Rating at last inspection (and update)

The last rating for this service was requires improvement (published 21 September 2018) and there were two breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection not enough improvement had been made/ sustained and the provider was still in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.


We have identified breaches in relation to medication management, risk management and governance systems at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the 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 carried out on 23 July 2018

During a routine inspection

This inspection took place on 23 July and 2 August 2018 and was unannounced.

Kirkella Mansions is registered to provide residential care for up to 25 older people who may be living with a dementia related condition. The service is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

The service provides accommodation across two floors. At the time of our inspection there were 21 people using the service.

The registered manager had been in post since 1 February 2012. 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.

At the last inspection in June 2017, we rated the service requires improvement overall and identified five breaches of regulation relating to safe care and treatment, safeguarding people from abuse, staffing, fit and proper persons employed and the governance of the service. This was because ineffective systems were in place to assess potential infection control risks to people’s health. The processes in place to report safeguarding concerns were not clear for staff to follow and had not been regularly updated. Not all staff had received safeguarding training, some staff had not received an appropriate induction to the service or received adequate supervisions and appraisals to support them in their role. The provider had not taken reasonable steps to ensure new staff were of suitable character to work in a care setting. Records were not always complete and contemporaneous in respect of people receiving a service. Quality assurance systems were not effective in monitoring and improving the quality of the service. We asked the provider to address our concerns.

At this inspection, we found that some improvements had been made. The provider had put measures in place to meet the breaches of regulation 13; Safeguarding people from abuse, 18; Staffing and regulation 19; Fit and proper persons employed. However, we identified two continued breaches of regulation 12; Safe care and treatment and regulation 17; Good governance.

Medicines were not always being administered as prescribed. We highlighted issues in the ordering, administration and recording of medicines. Complete and contemporaneous records were not always in place for the administration of medicines.

Staff knew people’s needs well and understood the importance of person-centred care. Care plans included information about people’s level of independence, preferences and religious or cultural backgrounds.

We identified some fire safety issues within the premises. These were discussed with the provider and they assured us these would be addressed immediately.

The environment was clean and staff followed good infection prevention and control practices. Improvements had been made to the decoration of the premises overall. However, we did identify some areas that required attention in relation to infection prevention and control. The provider told us this was a work in progress to ensure all areas were addressed in a timely manner.

Staff had received training in infection control procedures. Measures had been taken to ensure bedrooms were fit for occupancy and posed no risks to people’s health or well-being. The laundry room had clear signage to ensure that clean and soiled items were kept separate to avoid cross-contamination. We found some areas that required attention such as, one radiator that had paint peeling off and skirting boards in a hallway that had been scuffed to the bare wood. The registered manager took steps to address these following our inspecti

Inspection carried out on 26 June 2017

During a routine inspection

The inspection of Kirkella Mansions took place on 26 and 27 June 2017 and was unannounced. At the last inspection on 28 April 2015, the service met all of the regulations under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Kirkella Mansions Residential Home provides accommodation and personal cares for up to 25 older people, some of whom may be living with dementia. It is situated in Kirkella, a village in the East Riding of Yorkshire and is on two floors with single and shared accommodation, three lounge areas, a dining room and accessible gardens. The service does not provide nursing care. There is a small car park to the rear of the building. At the time of our visit, 21 people were living at the service, including one person who was having respite care with a view to permanency.

The registered provider was required to have a registered manager in post. 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. The home had a registered manager who had been in post for five and a half years. They will be referred to as ‘the manager’ throughout the report.

The provider had systems in place to identify, monitor and report potential or actual safeguarding concerns. However, we found that the policies and procedures in place were not reviewed and did not always contain up to date information. Staff training was not refreshed on a regular basis and as a result, one member of staff was unsure of the process to refer safeguarding concerns to external agencies if needed.

Recruitment policies and procedures were in place. However, the providers recruitment checks were not robust. We found that references had not been recorded or sufficient checks made to employ suitable persons of good character.

We identified areas of infection control that needed attention - two bedrooms had damp patches on the walls and one of those showed signs of mould which could potentially affect the health and wellbeing of people using the service. We saw that the laundry room had no guidance for staff to identify the clean and dirty working areas, which increased the risks of infection by cross contamination of clean and soiled items.

An induction training programme was in place and this included a checklist of policies and procedures that were made available to staff. However, new staff had not always completed the induction training.

There was a training matrix in place, although we could not see clear systems to identify when refresher training was due.

We also found that competency checks had not been carried out regularly, supervisions were not up to date and appraisals had not been completed in line with the provider’s policies and procedures.

We observed positive interactions between people who lived at the home and staff. People told us that staff were kind and caring and that they respected their privacy and dignity.

People's nutritional needs had been assessed and were being met by staff. People told us they were happy with the meals provided by the home although one person said the menu was a little repetitive.

People were happy with the activities on offer at the home; these included trips out to local places of interest.

We were told that the culture of the service was 'open and transparent'. People were given various opportunities to give feedback about the service they received.

You can see what action we told the provider to take at the back of the full version of the report.

Inspection carried out on 28 April 2015

During a routine inspection

The inspection of Kirkella Mansions took place on 28 April 2015 and was unannounced. At the previous inspection on 15 October 2013 the regulations we assessed were all being complied with.

The service provides care and accommodation to a maximum of 25 older people who may be living with dementia. The premises consist of single bedroom accommodation, three lounge areas, a dining room and accessible gardens. There is a hairdressing room, communal bathrooms, kitchen and laundry.

The service had a registered manager in post who had been the registered manager for the past three years. 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.

When we visited the service people we spoke with told us they were satisfied with the care they received, but that they would have preferred more staff to be on duty. They said they liked the food they were given and usually got on well with each other and the staff.

We found that the service had systems in place to protect people from harm or abuse and that staff were knowledgeable about these systems. Staff understood their responsibilities to ensure people were safeguarded from harm and knew how to pass information of suspected or actual abuse to the appropriate safeguarding authorities, because they had been trained in safeguarding adults from abuse. We saw evidence of this on the staff training record.

We found that people were protected from harm in their everyday lives because risk assessments were in place to reduce any risk activity they undertook. Staff adhered to these risk assessments to ensure any risks people faced were reduced.

The premises at Kirkella Mansions were safe because they were kept under review and repair, but there were some minor areas for improvement, which had not impacted on people that used the service.

We found that staff had emergency contingency plans in place and we saw these were held in the service office.

We saw there was a whistle blowing procedure in place which was in written format. We found that staff had not had to use the whistle blowing procedure for any reason in several years.

We found there were sufficient numbers of qualified and experienced staff on duty to meet people’s personal care and health care needs. We found that staff were satisfied with the staffing levels as they covered each other’s absences and felt they had some time to spend socialising with people.

We saw that satisfactory recruitment systems were in place and followed to ensure staff employed were suitable to care for vulnerable people. Staff corroborated they had followed these recruitment procedures.

We found that management of medicines was safe. Staff were trained in the management of medicines and we observed that staff administered them safely. Records were accurately maintained though we identified a couple of minor recording errors. These had not impacted on people that used the service. Staff followed safe procedures with ordering, receipting, storing, administering and disposing of medicines.

We found that infection control and food hygiene practices were safe and protected people from harm, although a minor improvement was required, which was reported in the full version of this report.

We found that the service provided effective care to people that used it, as there were sufficiently skilled staff caring for them. Staff were well supported by the provider and registered manager. The service followed the principles of the Mental Capacity Act 2005, ensured people’s nutritional needs were met and assisted them to maintain good health where possible.

However, the premises were not conducive to caring effectively for people living with dementia and improvements were needed in this area. There was a need to consider the development of an environment that was suitable for people living with dementia, as the premises had not been upgraded for a few years and previous work had not been carried out with people living with dementia in mind.

People that used the service were treated kindly and compassionately by the staff and were fully involved in their care wherever possible. They were given time to exercise independence, their privacy and dignity were maintained and they were well cared for when they were ill. The service went ‘that extra mile’ when it came to providing people with an individualised approach to their wellbeing.

We found that people had person-centred care plans in place that instructed staff how best to support them and meet their needs. Information also contained details about their interests and social preferences. People had effective systems in place to make complaints and have these resolved.

We found that people had access to the manager via an open management style and the culture of the service was one based on a caring ‘family’ approach, meeting individual needs. There was opportunity for people to be consulted using satisfaction surveys and meetings and audits were completed to check for shortfalls in service provision.

Inspection carried out on 15 October 2013

During a routine inspection

We spoke with people that used the service and some relatives about consent and we found that before people received any care they were asked for their consent and the provider acted in accordance with their wishes.

When we spoke with people, observed their interactions with each other and staff and viewed their care plans we found care was planned and delivered in a way that was intended to ensure peoples' safety and welfare. People said, "There are enough people around to ask for help when I need support", "I know the place well...staff are alright with me", "It's alright here, the girls are good" and "This is not really my scene. I am sometimes unhappy with what I see and would much rather be at home".

We found that people were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage them. People received their medication in a timely manner and were satisfied with the arrangements in place to manage it.

When we assessed the staffing levels in the service we found that there were enough qualified, skilled and experienced staff to meet peoples' needs.

There was an effective quality monitoring system in operation and an effective complaint system available, so people were able to contribute to the service provision and to make changes to how care was provided.

Inspection carried out on 15 May 2012

During a routine inspection

We spoke with people that used the service and they told us they were quite satisfied with the way in which they were included in planning and deciding the care and support they needed.

People told us that they were satisfied with the care and support they received. They told us they were satisfied with everything.

One person said, "You cannot fault the staff. They treat everyone with the same regard."

Another person said, "The girls are wonderful and I keep cheerful. Everyone is very good here really and there is nothing wrong with the home."

People we spoke with told us they felt quite safe living in the home.

A relative we spoke with said, "My wife couldn't ask for more, she is content and I am happy with the care she receives. I know she is looked after."