CQC report explained · a residential care home
What the CQC found at 3 to 5 Kennet Way
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough staff, safe medicine systems, suitable safeguarding arrangements and plans to manage risks. Fire safety recommendations had not always been acted on promptly, although action was taken after the inspection.
- Effective?
- Good
- People had appropriate consent and capacity arrangements, trained staff, support with food and healthcare, and coordinated input from professionals. This rating improved from Requires Improvement at the previous inspection.
- Caring?
- Good
- Staff treated people with dignity, respect and patience. People and relatives were involved in care planning and everyday choices.
- Responsive?
- Good
- Care plans reflected people's routines, sensory needs and communication methods. People were supported with activities, relationships, complaints and community involvement.
- Well-led?
- Requires improvement
- Leadership was positive and staff roles were clear, but management had not shown that all external fire safety recommendations had been acted on. Audits had also found errors in medicines administration records.
What inspectors found, January 2020
Rated Good overall, but well-led was Requires Improvement because fire safety actions and medicines records needed closer attention.
This was an unannounced planned inspection on 9 January 2020. One inspector observed care, spoke with relatives, the manager and staff, and checked care, medicine, recruitment and management records.
The home supported three people with learning disabilities and related conditions. Inspectors found people were safe, received effective care, were treated kindly and respectfully, and had personalised support, activities and communication arrangements.
The main weakness was leadership and oversight. The provider had not acted promptly enough on recommendations from an external fire risk assessment, and audits had found some medicines recording errors. The fire safety issues were addressed quickly after the inspection.
The overall rating stayed Good, as did Safe, Effective, Caring and Responsive. Well-led fell from Good at the previous inspection to Requires Improvement.
Kind and respectful staff
Relatives described people as happier and said staff understood their needs. Inspectors found staff were patient and protected people's dignity and privacy.
“Staff understood people's needs and were motivated in their role. They treated people with dignity, respect and were patient when they offered support.” from the report
Activities and relationships
People were supported to take part in activities suited to their interests, including community activities and holidays. Staff also helped people keep in contact with relatives.
“There is a regular and supportive activity programme. Staff have done an excellent job in supporting two short holidays, which were both very successful” from the report
Health support
People had health plans and were supported to attend appointments. Relatives said health was monitored and medical conditions were managed well.
“Health is well monitored and the GP consulted as necessary” from the report
Fire safety follow-up
needs fixingThe provider had not acted promptly enough on eight findings from an external fire risk assessment. One finding was high priority and related to access to fire escapes, although additional measures were put in place after the inspection.
“The provider did not always take responsive action to mitigate the risks identified by external stakeholders.” from the report
Medicines recording
needs fixingManagement audits found some errors in records showing medicines had been administered. The provider was addressing these with staff.
“Through these audits, the manager had identified some errors in the recording of the administration of medicines.” from the report
Reliance on agency staff
minorVacancies were being covered by agency staff while the provider recruited more permanent staff. A relative said a stable team was vital, although regular agency staff had been inducted.
“Currently there is a strong reliance on agency staff (several of whom are long term and excellent) but a renewed stable team is vital.” from the report
- 01What actions were taken to address the high-priority fire escape issue, and has the local fire and rescue service confirmed that the new arrangements are safe?
- 02What medicines recording errors were found, and how do you check that they have been resolved?
- 03How many permanent staff vacancies are there now, and how often are agency staff used?
- 04How will the manager's application to register with CQC be progressed?
- 05How are people being supported to gain more safe access to the kitchen and develop everyday living skills?
This was an unannounced planned inspection covering all five key questions, with the care home premises and care provided both considered. This explanation was written from the published report of 28 January 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, July 2017
3 to 5 Kennet Way was rated Good overall; inspectors found kind, personalised care, but the Effective rating was Requires Improvement because some Mental Capacity Act decisions were not fully recorded.
This was an unannounced inspection on 19 June 2017. The inspector spoke with staff, the manager, relatives and a social care professional. They checked care plans, medicine records, recruitment files, training records, staffing rotas, audits and other documents, and observed care.
The home was rated Good for Safe, Caring, Responsive and Well-led. Inspectors found that people were protected from abuse, risks were assessed, medicines were managed safely, and there were enough staff to meet people's needs. Staff were described as kind, respectful and knowledgeable about the people they supported.
The Effective rating was Requires Improvement. Some best-interest decisions and mental capacity assessments had not been fully recorded. The provider took immediate action during the inspection to complete these processes. This was the first inspection since the home was registered in April 2016.
Kind and respectful care
Staff developed close relationships with people and adapted their communication to each person's needs. Inspectors saw care being delivered sensitively and respectfully.
“Staff had taken time to develop close relationships with the people they were assisting.” from the report
Safe support
Risks linked to health conditions and behaviour were identified, with clear guidance for staff. Recruitment checks, staffing arrangements and medicine systems also supported safety.
“Risks to people's health and wellbeing had been identified and guidance provided to mitigate the risk of harm to them and other people.” from the report
Personalised activities
People were supported to choose activities that suited their interests and to take part in community life. Their routines could change when they changed their minds.
“All the people in the home were supported to take part in activities in the local community.” from the report
Mental capacity records
seriousFor some people, best-interest decisions and applications linked to restrictions on liberty had not been fully discussed or recorded. Another person had not had a full mental capacity assessment before covert medication was used, although immediate action was taken.
“However, when people had been assessed as not having the capacity to make key decisions about their care, the provider had not always documented that actions taken were in people's best interests.” from the report
Use of agency staff
needs fixingThe home was regularly using agency staff because of recruitment difficulties. The report says the same agency staff were used to support continuity, but this is worth discussing if consistency is important for the person.
“The home was regularly using agency staff to support existing staff at the home at the time of the inspection owing to staff recruitment difficulties.” from the report
Staff supervision
needs fixingPlanned staff supervision had not always taken place in line with the provider's guidance while the deputy manager was away. Records showed that supervision was due during and immediately after the inspection.
“However owing to the deputy manager currently being away from the home these had not always been happening in line with the provider's guidance.” from the report
- 01How have you completed and checked the best-interest records identified during the inspection?
- 02How do you make sure every person has a current Mental Capacity Act assessment before decisions are made for them?
- 03How often are agency staff used now, and how do you maintain consistency for people who find changes difficult?
- 04Are staff supervisions now taking place at the planned frequency?
- 05How are relatives involved in care planning and in decisions about restrictions or covert medication?
This was an unannounced inspection of the overall service, covering all five CQC questions and providing the home's first rating since registration in April 2016. This explanation was written from the published report of 29 July 2017 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of 3 to 5 Kennet Way
2 rated inspections over 2 years: the service has held its Good rating throughout.
- January 2020Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2017GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- April 2016
Registered with the Care Quality Commission on 4 April 2016.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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