Kirkley Manor

Updated 27 September 2018

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 comprehensive inspection was carried out by two inspectors and an Expert by Experience on 22 and 28 August 2018 and was unannounced. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Prior to the inspection we reviewed the contents of notifications received by the service. Services have to notify us of certain incidents that occur in the service, these are called notifications.

We used information the provider sent us in the Provider Information Return. This is information we require providers to send us at least once annually to give some key information about the service, what the service does well and improvements they plan to make.

Some people using the service were unable to communicate their views about the care they received. We therefore carried out observations to assess their experiences throughout our inspection. We spoke with five people using the service, three relatives, four care staff, the cook, a domestic staff member, the registered manager and two senior managers representing the provider.

We reviewed 12 care records, three staff personnel files and a sample of records relating to the management of the service.

Updated 27 September 2018

Kirkley Manor is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Kirkley Manor is registered to provide personal and nursing care to a maximum of 71 older people.

At our last inspection we rated the service good. At this inspection we found the evidence continued to support the rating of good and there was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

The service continued to protect people from the risks of abuse or avoidable harm and risks to people were identified and planned for. Medicines were managed and administered safely and the premises remained clean and there were processes in place to reduce the risk of the spread of infection.

The service continued to ensure that there were enough staff to meet people’s needs in a timely way and that recruitment procedures were safe.

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 continued to support this practice.

The service provided people with a choice of adequate food and drink. Support people required to maintain good nutrition and hydration was reflected in care planning. People were supported to have contact with other health professionals where appropriate.

People received care from staff who had the training, skills and experience for the role. The service continued to promote and reward excellence in staff practice.

People told us staff were kind to them and the service continued to promote a culture of kindness, with the registered manager, staff and senior managers leading this practice.

The service continued to offer people personalised care based on their individual preferences and to involve people and their representatives in the planning of care.

People were provided with adequate sources of meaningful engagement and were supported to feedback their views and experiences through meetings and surveys. People were made aware of how they could complain and the service continued to respond to complaints appropriately.

The registered manager and other staff were undertaking training on the Gold Standards Framework for end of life care in order to make and maintain improvements to care planning.

The registered manager, senior managers and the provider continued to operate an effective system to monitor the quality of the service provided to people. Areas for improvement were identified and acted upon. The service continued to work towards an improvement plan which set out future changes and improvements to the service people were provided with.

Further information is in the detailed findings below.