We inspected Kirkley Lodge on 19 October 2017. The inspection was unannounced which meant the provider and staff did not know we would be visiting.

Kirkley Lodge is registered to provide care and accommodation to 47 older people and older people who are living with a dementia type illness. At the time of the inspection there were 45 people who used the service.

At the last inspection in July 2015, the service was rated 'Good'. At this inspection we found the service remained 'Good'.

At the time of the inspection the service did not have a registered manager. 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 a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The service had a manager who had returned to the service after a period of leave and was in the process of applying to the Care Quality Commission to be the registered manager. Whilst the manager had been on leave there had been another experienced registered manager in post who had previously worked at Kirkley Lodge for many years.

Staff understood the procedure they needed to follow if they suspected abuse might be taking place. Risks to people were identified and plans were put in place to help manage the risk and minimise them occurring.

Medicines were managed safely with an effective system in place. We did note that staff were not signing at the time when they applied creams, they were signing later in the day. We pointed this out to the manager who told us they would take action to address this.

Appropriate checks of the building and maintenance systems were undertaken to ensure health and safety was maintained.

People and relatives told us there were enough staff on duty to meet the needs of people. We found that safe recruitment and selection procedures were in place and appropriate checks had been undertaken before staff began work.

People were supported by a regular team of staff who were knowledgeable about people’s likes, dislikes and preferences. A training plan was in place and all staff had completed up to date training.

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

People were provided with a choice of healthy food and drinks, which helped to ensure that their nutritional needs were met. We looked at records to confirm staff weighed people. Staff at the service had identified some people who used the service had lost weight and needed to be weighed on a weekly basis to keep track of this. However, examination of records identified that staff had not always weighed people at weekly intervals. We pointed this out to the manager who told us they had already identified this and on their return from leave. They told us they had reviewed all people’s weights and nutritional assessments and would be regularly monitoring this.

People were supported to maintain good health and had access to healthcare professionals and services.

There were positive interactions between people and staff. We saw staff treated people with dignity and respect. Staff were kind and caring. Observation of the staff showed that they knew the people very well and could anticipate their needs.

Care plans detailed people’s needs and preferences. Some care plans had not been evaluated since July 2017. We pointed this out to the manager who told us they would take action to review and update these as a matter of importance. People were actively involved in care planning and decision making. People who used the service had access to a range of activities and leisure opportunities.

Systems were in place to monitor and evaluate any concerns or complaints received and to ensure

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We inspected Kirkley Lodge on 21 July 2015. The inspection was unannounced which meant that the staff and registered provider did not know that we would be visiting.

Kirkley Lodge is a two-storey purpose built care service that is registered to provide care to a maximum number of 47 older people across three units. Primrose and Roseberry units are on the ground floor. Primrose has 11 beds for people who have been identified as having ‘extra care needs’ whilst Roseberry has 12 beds for those people living with a dementia. Peacehaven is on the first floor and is a 24 bedded unit for people receiving personal care.

The home had a registered manager in place. 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 our last inspection of the service on 9 and 17 July 2014 we found that care records were not always accurate or fit for purpose. The registered provider sent us an action plan telling us they would be compliant by 30 June 2015. We checked care records at this inspection and found that improvements had been made.

There were systems and processes in place to protect people from the risk of harm. Staff were able to tell us about different types of abuse and were aware of action they should take if abuse was suspected. Staff we spoke with were able to describe how they ensured the welfare of vulnerable people was protected through the organisation’s whistle blowing and safeguarding procedures.

Appropriate checks of the building and maintenance systems were undertaken to ensure health and safety. However we did notice that some water temperatures of showers were too cool. This was pointed out to the registered manager at the time of the inspection who told us they would take action to rectify the temperatures.

The care plans we looked at incorporated a series of risk assessments. They included areas such as the risks around moving and handling; going out; falls; skin integrity. nutrition and hydration. This helped to ensure people were supported to take responsible risks as part of their daily lifestyle with the minimum necessary restriction.

We saw that staff had received supervision on a regular basis and an annual appraisal.

Staff had been trained and had the skills and knowledge to provide support to the people they cared for. From the people and relatives we spoke with we received an even split as to whether people thought there was enough staff on duty to meet people’s need. We asked the registered manager to review their dependency levels of people who used the service to determine if there are sufficient staff on duty.

The registered manager understood the requirements of the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards (DoLS) which meant they were working within the law to support people who may lack capacity to make their own decisions. However some staff had limited knowledge of MCA (2005) and DoLS.

We found that safe recruitment and selection procedures were in place and appropriate checks had been undertaken before staff began work. This included obtaining references from previous employers to show staff employed were safe to work with vulnerable people.

Appropriate systems were in place for the management of medicines so that people received their medicines safely. However, we saw that the temperature of some rooms in which medicines were stored in were on occasions too high. If medicines are not stored at the correct temperature they may not work in the way they were intended, and so pose a potential risk to the health and wellbeing of the person receiving the medicine.

There were positive interactions between people and staff. We saw that staff treated people with dignity and respect. Staff were attentive, respectful, patient and interacted well with people. People told us that they were happy and felt very well cared for.

We saw that people were provided with a choice of healthy food and drinks which helped to ensure that their nutritional needs were met. Menus were varied and had been looked at to ensure that they were nutritious.

People were supported to maintain good health and had access to healthcare professionals and services. People were supported and encouraged to have regular health checks and were accompanied by staff to hospital appointments.

We saw people had been assessed and had plans of care in place. Some of the care plans we looked at would benefit from more detail to ensure that records detailed clearly how to meet the care and support needs of people.

At the time of the inspection the registered manager was looking to recruit an activity co-ordinator to plan and deliver activities to people who used the service. The previous activity co-ordinator had left two weeks before the inspection and in the interim care staff were delivering activities for people. We received mixed responses in terms of activities, some people preferred to spend time on their own and chose not to join in activities. Some people were happy with the level of activities but some felt that more activities could be taking place.

The registered provider had a system in place for responding to people’s concerns and complaints. People were asked for their views. People said that they would talk to the registered manager or staff if they were unhappy or had any concerns.

There were systems in place to monitor and improve the quality of the service provided. We saw there were a range of audits carried out both by the registered manager and senior staff within the organisation. We saw where issues had been identified; action plans with agreed timescales were followed to address them promptly.

We spoke with five people who used the service. They all told us they were treated well, the staff were good and they enjoyed living at the home. One person said, “They are all very nice here, they help in any way they can.” Another person told us, “I am definitely getting the care I need, I have been happy since the day I came here.”

We spoke with three relatives of people who used the service and they were all happy with the care provided. One relative said, “The care is excellent I would recommend the place to anyone.” We found that people experienced care that met their individual needs.

We observed staff interacting well with people and saw there was a calm, friendly and relaxed atmosphere between people living and working at the home. One person told us, “There are always things to do, it’s very entertaining.” One relative told us, “There are plenty of activities and the relatives get involved as well.” This contributed to maintaining people's welfare and promoting their wellbeing.

We found that people who used the service had a choice of food and drink and this was readily available.

We found that staff had received regular training and supervision sessions had just commenced under the new management. Staff told us they were working in a supportive environment.

We found there were effective systems to regularly assess and monitor the quality of service that people received.

We spoke with five people who use the service. They told us they were treated well, the staff were nice and they felt safe at the home. One person said “I couldn’t be happier.” Another person told us “The staff couldn’t be more helpful”, and “The food is marvellous.”

People who use the service told us there were a number of activities run within the home. One person said a local school choir had come to the home to sing and that “It was nice.” Another person told us they had recently been to the local garden centre on a trip and had enjoyed it.

We saw there was a friendly and relaxed atmosphere between people living and working at the home. We observed staff interacting well with people and supporting them which had a positive impact on their wellbeing.

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008 and to pilot a new inspection process being introduced by CQC which looks at the overall quality of the service.  

We last inspected Kirkley Lodge on the 7 August 2013 and found the service was not in breach of any regulations at that time.

Kirkley Lodge is a 47 bedded care home providing care to older people with a range of needs.  This care is provided within three distinct units.  Primrose  which provides care for up to 12 people who are living with a dementia; Roseberry which provides care for up to 11 people with enhanced personal care needs and Peacehaven, which provide personal care for up to 24 people.  At the time of the inspection there were 46 people living at the service. 

There is a registered manager in post who has been registered with the Care Quality Commission since February 2014.  A registered manager is a person who has registered with the Care Quality Commission to manage the service and shares the legal responsibility for meeting the requirements of the law; as does the provider.

The inspection visit took place over two inspection days, with the first day being unannounced.

People had their needs assessed before moving into Kirkley Lodge.  Whilst people had their care needs assessed not all records had been fully completed or were up to date.  Care records did not always contain sufficient information and there were areas of need where care plans had not been developed. 

We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.  The registered person did not ensure that service users were protected against the risks of unsafe or inappropriate care and treatment.  Care records were not accurate or fit for purpose. 

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

People told us they felt safe living at Kirkley Lodge and we saw there were systems in place to protect people against risk of harm. 

There were policies and procedures in place in relation to the Mental Capacity Act 2005 and Deprivations of Liberty Safeguards (DoLS).  The registered manager and staff had completed training and knew the procedures to follow. 

We found that people were cared for by staff who had the knowledge and understanding to meet their needs.  Robust recruitment processes were in place and followed, and appropriate checks had been undertaken before staff began working at the service.  This included obtaining references from their previous employer and also check to show that staff were safe to work with vulnerable adults.

An appropriate skill mix of staff was in place.  A review of staffing numbers had been completed and recruitment was underway to increase the staff within one of the units.

Staff were provided with training appropriate to their job role.  Staff supervision had not taken place as frequently as needed, however the registered manager had taken action to address this. 

Good arrangements were in place to ensure that people’s nutritional needs were met and where necessary people had input from dieticians or speech and language therapists.  People told us they liked the food and had sufficient choice and variety.

Suitable arrangements were in place to meet people’s healthcare needs.  People had access to healthcare professionals and services.

People and visitors told us they were supported by caring staff and they were treated with dignity and respect.  Staff were aware of the values of the service and of the need for person centred care. 

We saw staff had developed relationships with people that were kind and caring.  We saw lots of positive engagement with people and there were lots of smiles and laughter. 

An activities person had recently been appointed and people were enjoying being involved in activities both within the service and on outings.

Appropriate systems were in place for the management of complaints.

There were effective systems in place to monitor and improve the quality of the service provided.