CQC report explained · a nursing home
What the CQC found at Hallmark Kew House Luxury Care Home
Rated Outstanding: inspectors found the home performing exceptionally well.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Inspectors found suitable staffing, recruitment, risk management, infection control and medicines systems.
- Effective?
- Outstanding
- This key question was not inspected during this visit, so no current rating was given in this report.
- Caring?
- Outstanding
- This key question was not inspected during this visit, so no current rating was given in this report.
- Responsive?
- Outstanding
- This key question was not inspected during this visit, so no current rating was given in this report.
- Well-led?
- Good
- Inspectors found stable and effective leadership, regular quality checks, an open culture and good partnership working. This rating fell from Outstanding at the previous inspection.
What inspectors found, October 2023
Overall rated Outstanding; inspectors found safe, person-centred care, while well-led fell from Outstanding to Good after a period of management change.
This was an unannounced inspection on 23 May and 1 June 2023. Three inspectors spoke with 9 people living in the home, staff and professionals. They observed care and lunch, and checked care plans, medicines records, recruitment files and management checks.
The home was rated Good for Safe. Inspectors found enough staff, thorough recruitment checks, clean premises, suitable risk assessments and well-organised medicines systems. People said they felt safe and staff knew how to respond to risks and safeguarding concerns.
The home was rated Good for Well-led. Inspectors found stable leadership after a period of management change, regular checks on quality and safety, and an open approach to feedback. People, relatives and staff were positive about the current management.
The overall rating remained Outstanding. However, this was a focused inspection of Safe and Well-led. The other key question ratings were not inspected and were carried over from the previous inspection.
Staffing and recruitment
Inspectors found enough staff to meet people's needs. Recruitment checks were thorough and included identity, employment, right-to-work and DBS checks.
“There were enough staff to meet people's needs. During our inspection, staffing levels matched the rota and enabled people's needs to be met safely.” from the report
Medicines
Medicines were administered, stored and checked safely. The electronic system helped keep records up to date, and inspectors found no recording errors or omissions in the records reviewed.
“We found no recording errors or omissions on any e-medicines records we looked at.” from the report
Person-centred care
Staff knew people's individual needs and preferences. Care plans contained detailed information about people's strengths, likes and dislikes.
“Staff demonstrated good person-centred awareness of people's individual care needs and interacted with them both in a respectful and considerate way.” from the report
Open management
The current management team was described as stable, approachable and willing to listen. The home used feedback, audits and action plans to improve care.
“Following a period of changing management, the current registered manager and her team clearly provided stable and effective leadership to the home.” from the report
Clean and hygienic home
Inspectors found the premises hygienically clean and saw infection prevention practices in place, including handwashing and hand gel use.
“People told us, and we saw that the care home, looked and smelt hygienically clean.” from the report
Well-led rating reduced
minorWell-led was rated Good rather than Outstanding because the report records a change in rating after a period of management change. Inspectors said the current leadership was stable and effective.
“At our last inspection we rated this key question outstanding. At this inspection the rating has changed to good.” from the report
- 01What steps are being taken to maintain the stable management team described in the report?
- 02How do you make sure there are enough suitably trained staff when people's needs change or staff are absent?
- 03How does the electronic medicines system identify and prevent medicines errors, and how are these checks reviewed?
- 04How often are care plans and risk assessments reviewed for changes in mobility, falls, nutrition and skin integrity?
- 05What recent quality improvements have come from feedback from residents, relatives and staff?
This was a focused inspection of Safe and Well-led only; the other key question ratings were not inspected and were carried over from the previous inspection. This explanation was written from the published report of 6 October 2023 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, December 2019
Rated Outstanding; inspectors found exceptionally caring, personalised and well-led care, with safety rated Good.
This was a planned inspection over two visits, on 29 July and 30 October 2019. Inspectors spoke with people living at the home, relatives, staff and visiting professionals. They also observed care and checked training, care records and quality checks.
The home was rated Outstanding overall. Effective, caring, responsive and well-led were all rated Outstanding. Safe was rated Good. Inspectors found enough staff, safe medicines management, protection from abuse and good infection control.
The report describes highly personalised care, especially for people living with dementia. People were supported to make choices, stay active, maintain relationships and follow their interests. The home also had strong systems for listening to people and improving the service.
There were a few issues to watch. Two pressure-relieving mattresses were set at incorrect levels, and the home had received complaints about belongings going missing. Inspectors raised the mattress issue with the manager and said they would check progress at the next comprehensive inspection.
Personalised dementia care
The home used a detailed dementia strategy to shape care and improve people's social engagement, communication and quality of life.
“The provider had a comprehensive, evidence-based dementia strategy in place that governed all aspects of service design and delivery” from the report
Kind and respectful staff
People and relatives consistently described staff as caring and respectful. Inspectors saw staff responding sensitively to people's needs.
“People were treated with dignity and respect.” from the report
Choice and independence
Risk assessments were used to help people continue activities they enjoyed, rather than simply restricting them.
“Risk assessments which considered people's mobility and motor controls (using hands and sight) were used to empower people rather than discourage them from doing what they wanted.” from the report
Activities and relationships
The home offered varied activities linked to people's past interests and helped them keep relationships with family, friends and the wider community.
“Kew House provided an extremely wide range of in-house and community activities enabling people to live fulfilled lives.” from the report
Open leadership
The manager was visible and approachable. People, relatives and staff were involved in decisions, and the home acted on their feedback.
“The registered manager was proactive in ensuring they had a visible presence within the home and operated an open-door policy” from the report
Mattress settings
needs fixingTwo pressure-relieving mattresses were set at incorrect levels, which could affect skin protection. The manager introduced extra checks and planned to replace the mattresses.
“We noted that two people's pressure-relieving mattresses were set at incorrect levels to protect their skin integrity.” from the report
Belongings going missing
minorFour formal complaints in the previous year concerned items going missing. The home responded by introducing an inventory checklist and photographing valuable property.
“In the previous 12 months four complaints had been made under the home's formal complaints procedure.” from the report
- 01What checks are now used to make sure pressure-relieving mattresses are set correctly?
- 02Have the mattresses with easily knocked controls been replaced, as planned in the report?
- 03How do you record and safeguard valuable belongings when someone moves in?
- 04How are families involved in care reviews and decisions about risks and personal choices?
- 05Which activities would be available for my relative's interests, communication needs and level of dementia?
This was a planned inspection of the care home, including its premises and the care provided, and it considered all five CQC questions. This explanation was written from the published report of 19 December 2019 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. The report was longer than we could read in one go; the later sections may not be reflected.
Every inspection of Hallmark Kew House Luxury Care Home
3 rated inspections over 7 years: the service has improved, from Good to Outstanding.
- October 2023Outstandingcurrent ratingstayed OutstandingSafe: GoodEffective: OutstandingCaring: OutstandingResponsive: OutstandingWell-led: Good
Read what inspectors found at Hallmark Kew House Luxury Care Home →
- December 2019Outstandingup from GoodSafe: GoodWell-led: Outstanding
Read what inspectors found at Hallmark Kew House Luxury Care Home →
- August 2016GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- July 2016
Registered with the Care Quality Commission on 11 July 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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