CQC report explained · a nursing home
What the CQC found at Kenbrook
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from avoidable harm. Inspectors found enough staff overall, safe medicines management, suitable risk assessments and systems for safeguarding and infection control, although some people waited too long for help during lunch.
- Effective?
- Good
- People's health, nutrition and hydration needs were assessed and supported. Staff were trained and supported, and the home worked with healthcare professionals and followed the Mental Capacity Act.
- Caring?
- Good
- People were treated with kindness, dignity and respect. Staff involved people in decisions, respected their choices and supported their cultural, religious and equality needs.
- Responsive?
- Good
- Care plans reflected people's needs and preferences. People were supported with communication, activities, relationships, visits and end-of-life care, and knew how to raise complaints.
- Well-led?
- Good
- Inspectors found approachable management, supportive staff and effective checks on quality. The home investigated incidents and complaints, shared learning and made improvement plans.
What inspectors found, October 2023
Rated Good; inspectors found kind, personalised care, with some improvements needed around mealtime support and food information.
This was an unannounced inspection on 26 September 2023. Inspectors spoke with people living at the home, relatives and staff. They observed care, checked 14 care records and reviewed medicines, recruitment, training, complaints, audits and the building.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found people were safe, well cared for and treated with kindness and respect. Care was personalised, medicines were managed safely, and people had access to healthcare, food, drinks and activities.
The inspection found some areas needing improvement, including delays for some people needing help during lunch, and better choice and information about food. The manager acted on these points, including changing staff arrangements at mealtimes and telling inspectors that missing menus and activity information had been put right.
Kind and respectful care
Inspectors saw staff giving people time and attention. People and relatives described staff as kind and caring.
“We observed the staff treating people respectfully and with kindness.” from the report
Personalised support
Care plans recorded people's needs, preferences and communication requirements. These plans were reviewed and staff followed them.
“People received personalised care which met their needs and reflected their preferences.” from the report
Safe medicines
Medicines were stored securely, records were accurate and audits gave inspectors confidence that medicines were given as prescribed.
“People received their medicines safely and as intended by the prescriber.” from the report
Good leadership and learning
Managers used audits, incidents, complaints and feedback to identify improvements. Staff said they felt supported.
“There were effective systems for monitoring and improving quality at the service.” from the report
Delays during lunch
needs fixingSome people had to wait a long time for help during lunch. The manager reviewed staff allocation and introduced a new system after inspectors raised this.
“However, during lunch some people had to wait a long time for support.” from the report
Food choice and information
needs fixingInspectors found that choice at the point of service, food variety and information about food could be improved. The manager had already identified this and showed plans to address it.
“We identified where some improvements could be made to improve choice at the point of service, variety, and information about food.” from the report
Information boards
minorMenus and activity planners were not displayed during the inspection. The management team later told inspectors this had been addressed.
“However, we noted that other information was not on display such as menus and activity planners.” from the report
- 01What changes have you made to staffing at mealtimes, and how do you check that people receive help without long waits?
- 02How are people offered choices at the point of service, and how has food variety been improved?
- 03Are menus and activity planners now available and kept up to date for people and visitors?
- 04How will you make sure each person's care plan continues to reflect their preferences and communication needs?
- 05How can relatives give feedback, and how will the home tell us what action has been taken?
This was an unannounced inspection covering all five CQC questions, including the premises, care provided, medicines and infection prevention measures; the previous overall rating was Good, published on 19 December 2017. This explanation was written from the published report of 10 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 2017
Rated Good; inspectors found kind, person-centred care, with some medicines recording and storage issues to address.
This was an unannounced inspection on 20 November 2017. Inspectors observed care, reviewed 14 care plans, six staff files and other records, and spoke with people, relatives, staff and care professionals.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People appeared relaxed and comfortable, and people and relatives generally said they felt safe and well cared for.
Inspectors found detailed care plans, suitable staff training, safe systems for risks and medicines, varied activities, and regular management checks. They also identified some medicines issues, including incomplete records for creams and ointments and a need for a risk assessment when medicines were self-administered.
Kind and respectful care
Inspectors saw people appearing relaxed and comfortable with staff. Staff were patient, respectful and communicated in ways people understood.
“During the inspection, we observed that the atmosphere in the home was warm and caring.” from the report
Personal care plans
Care plans included people's preferences, routines, communication needs and the support they needed. Staff knew people's likes and dislikes.
“Care plans were person-centred, specific to people's needs and detailed the support people needed in all areas of their care.” from the report
Activities and inclusion
The home offered a range of activities and also had a therapeutic programme for people who could not join group activities.
“There was a therapeutic programme for people who were unable to participate in group activities and staff ensured they spent time interacting with these people.” from the report
Medicine trolley temperature
needs fixingStaff were not monitoring the temperature of the room where one medicine trolley was kept. The manager said the trolley would be moved and temperatures checked.
“However, we found staff were not monitoring the temperature of a room where one medicine trolley was being stored.” from the report
Unsupervised medicines
needs fixingOne person was given medicines to take without supervision, but the home had not assessed the risks of this. Inspectors asked for a thorough risk assessment.
“We recommend that a thorough risk assessment should be carried out when medicines are left with people unsupervised for self-administration.” from the report
Incomplete medicines records
needs fixingRecords were not completed when staff applied creams and ointments. This could make it harder to check whether these medicines had been given as planned.
“We noted that where staff were applying external medicines such as creams and ointments, they were not completing the records.” from the report
Some delay at lunch
minorInspectors saw some people waiting for food and lunch on one floor took about an hour and 15 minutes. The manager said this happened occasionally because many people had complex needs.
“We observed that there was some delay with people receiving their food, but noted that there were adequate staffing numbers on the ground floor.” from the report
- 01What action have you taken about checking the temperature of the room where medicines are stored?
- 02How do you assess and review whether a person can safely self-administer medicines?
- 03How are records for creams and ointments completed and checked now?
- 04How do you reduce delays at mealtimes for people with complex needs?
- 05How are care plans and risk assessments updated when a person's needs change?
This was an unannounced comprehensive inspection covering all five key questions, and the previous Good ratings from November 2015 remained Good. This explanation was written from the published report of 19 December 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 Kenbrook
3 rated inspections over 8 years: the service has held its Good rating throughout.
- October 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2014
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 22 December 2010.
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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