CQC report explained · a nursing home
What the CQC found at Kenilworth Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from avoidable harm, with risk assessments, safeguarding systems, enough staff and generally safe medicines management. Inspectors found several small issues, including incorrect mask use, a fire door problem and one missing medicine protocol, which were addressed.
- Effective?
- Good
- This key question was not inspected during this visit. Its previous rating was used in calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this visit. Its previous rating was used in calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this visit. Its previous rating was used in calculating the overall rating.
- Well-led?
- Good
- Managers were described as approachable and clear about their responsibilities. The home used audits, meetings, feedback and partnership working to monitor and improve care.
What inspectors found, December 2021
Kenilworth Nursing Home was rated Good; inspectors found people were safe and the home was well managed, with a few issues fixed during the visit.
This was an unannounced focused inspection on 29 October 2021. Inspectors reviewed Safe and Well-led only because concerns had been raised about health-related risks. They spoke with four people, eight staff members and six relatives, and reviewed care, medicines, recruitment and management records.
The home was rated Good for Safe and Well-led, and Good overall. Inspectors found enough staff, suitable risk assessments, safe medicines management overall, appropriate infection control systems and proper investigation of incidents, safeguarding concerns and complaints.
Some problems were found and fixed during or shortly after the inspection. These included staff wearing masks incorrectly, a fire door problem, a missing protocol for one as-required medicine and incomplete COVID-19 risk assessments for staff. The other three areas, Effective, Caring and Responsive, were not inspected at this visit, so their previous ratings were carried forward.
Enough staff
Inspectors saw staff available throughout the visit and responding to requests promptly. Relatives also said there were plenty of staff.
“There were enough staff to meet people's needs and keep them safe.” from the report
Risk management
The home had a range of risk assessments, including for falls, skin care, behaviour and self-neglect. These were reviewed and included steps to reduce risks.
“The risk assessments had information about how to reduce the risk and were reviewed regularly so they were relevant to the person's needs.” from the report
Safeguarding and learning
Safeguarding concerns, incidents and complaints were recorded and investigated. The home notified relevant agencies and used outcomes to reduce the chance of problems happening again.
“Incidents and accidents were appropriately recorded and investigated, and outcomes included actions to help prevent future reoccurrence.” from the report
Approachable management
People, relatives and staff said managers listened and acted on concerns. The home also held resident meetings and invited people to take part in care plan reviews.
“People and their relatives were satisfied with the care provided.” from the report
Working with professionals
The home made referrals and worked with mental health professionals, the local authority, GPs and clinical commissioning groups to support people's health and wellbeing.
“Records indicated the provider made timely referrals and worked with mental health professionals, the local authority, GP and local Clinical Commissioning Groups (CCGs).” from the report
Mask use
minorSome staff were seen wearing their masks below their noses. This was corrected immediately when inspectors pointed it out.
“We did observe some staff with their face mask under their nose, but this was fixed immediately when we pointed it out.” from the report
Fire door
needs fixingA fire door stop battery was not working and the door had been propped open. The problem was resolved during the inspection.
“However, we did see a fire door stop battery not working and the door propped open, but this was resolved during the inspection.” from the report
As-required medicine protocol
needs fixingOne prescribed as-required medicine did not have the required administration protocol. It had not been given, and the provider put the correct protocol in place during the inspection.
“We saw a prescribed 'as required' medicine did not have appropriate administration protocols in place.” from the report
Staff COVID-19 risk assessments
minorPeople had individual COVID-19 risk assessments, but staff assessments were initially general. The provider sent completed staff assessments after the inspection.
“People using the service had individual COVID-19 risk assessments, but staff risk assessments were general.” from the report
- 01How do you now check that all staff wear personal protective equipment correctly?
- 02What checks are in place to make sure fire doors and their safety equipment are working?
- 03How are as-required medicines authorised, documented and reviewed?
- 04Have individual COVID-19 risk assessments been completed for all staff?
- 05What were the previous ratings for Effective, Caring and Responsive, and when will these areas next be inspected?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not inspected and their previous ratings carried over into the overall rating. This explanation was written from the published report of 1 December 2021 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, September 2020
Inspected but not rated; inspectors found strong infection control arrangements during the coronavirus pandemic.
This was an announced, targeted inspection on 12 August 2020. It looked at infection prevention and control measures as part of a coronavirus pandemic review.
Inspectors were assured that the home managed visitors, shielding, social distancing, admissions, protective equipment, testing, hygiene and possible outbreaks appropriately. They also found that the infection control policy was up to date.
The home had an outside visiting area with handwashing facilities and protective equipment. It worked with the local authority and Public Health England, supported staff, and prepared supplies and risk assessments before lockdown.
The overall service was inspected but not rated. The Safe question was also inspected but not rated. This report does not provide ratings for the other four questions.
Safe visiting arrangements
Visitors booked in advance, were screened by phone and agreed to follow the home's procedures. The home also created an outside visiting area with a sink and protective equipment.
“Visitors agreed a visiting time in advance, were screened over the phone and agreed to follow the visiting procedures.” from the report
Good partnership working
The provider worked with the local authority and Public Health England. It also kept links with other care homes to share ideas.
“The provider worked closely with the local authority and attended all meetings and training on offer from the local authority and PHE.” from the report
Support for staff
The provider supported staff and made sure they had equipment, risk assessments and training. It also paid for taxis to and from work.
“The provider was very conscious of their staffs' needs and invested in them, for example paying for taxis to and from work.” from the report
Early preparation
The home prepared before lockdown and kept supplies of protective equipment, food and cleaning products. It continued to monitor these supplies.
“They began preparing early through their own initiative and completed risk assessments around PPE, food and cleaning products so they were always well stocked.” from the report
Infection control
Inspectors were assured that protective equipment was used safely and that the home had arrangements for preventing, identifying and managing infections.
“We were assured that the provider was using PPE effectively and safely.” from the report
Inspectors raised no specific concerns in this report.
- 01How have your visitor screening and visiting arrangements changed since the August 2020 inspection?
- 02How do you currently provide and check staff training on infection prevention and control?
- 03How do you make sure protective equipment, food and cleaning products remain fully stocked?
- 04What is your current process for testing people using the service and staff?
- 05How would you manage an infection outbreak now, and when was this plan last reviewed?
This was a targeted inspection of infection prevention and control measures during the coronavirus pandemic; the service was inspected but not rated and the other areas were not assessed. This explanation was written from the published report of 10 September 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.
Every inspection of Kenilworth Nursing Home
7 rated inspections over 6 years: the service has improved, from Requires improvement to Good.
- December 2021Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2020Inspected but not ratedSafe: Inspected but not rated
- August 2019Goodup from Requires improvementSafe: GoodWell-led: Good
- July 2018Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2017Goodup from Requires improvementSafe: GoodWell-led: Good
- July 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- August 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 28 January 2011.
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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