CQC report explained · a nursing home
What the CQC found at Kenmore
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- People were generally protected from abuse and medicines were managed safely, but pressure mattress settings were incorrect for some people. Night staffing was reviewed and increased after the inspection.
- Effective?
- Good
- People received enough food and drink, accessed healthcare when needed and were supported by trained staff. Records about capacity and consent, including covert medicines, needed improvement.
- Caring?
- Good
- This question was not inspected during this focused inspection. Its rating was carried over from the previous inspection when calculating the overall rating.
- Responsive?
- Requires improvement
- This question was not inspected during this focused inspection. Its rating was carried over from the previous inspection when calculating the overall rating.
- Well-led?
- Requires improvement
- Oversight had improved, but audits did not identify all shortfalls, including pressure mattress checks and capacity records. Night care concerns were investigated and action was started.
What inspectors found, March 2023
Kenmore is rated Requires Improvement; care was often kind and effective, but safety checks and person-centred night care needed improvement.
This was an unannounced focused inspection on 10 and 16 January 2023. Inspectors spoke with people living at the home, relatives, managers and staff. They observed care and reviewed care records, medicine records, staff rotas and other documents.
The home was rated Requires Improvement overall. Safe and well-led were also rated Requires Improvement. Inspectors found risks with pressure mattress settings, records about capacity and consent, and night-time routines that could encourage people to go to bed before night staff arrived.
Effective was rated Good. People generally received enough food, drink and healthcare. Medicines management, infection control and recruitment had improved. The home was no longer in breach of regulations found at the previous inspection, but this was the third consecutive Requires Improvement rating.
Improved medicines management
Inspectors found that medicines were generally managed safely and records showed people received medicines as prescribed.
“Medication records showed people received their medicines as prescribed and the administration process we observed was safe.” from the report
Food and drink
People were supported to have enough to eat and drink. Staff understood dietary needs, including modified and diabetic-friendly diets.
“People were supported to have enough to eat and drink.” from the report
Healthcare support
People's healthcare needs were generally responded to, with staff working with healthcare professionals when treatment was needed.
“Care records we looked at showed appropriate action was taken in response to an indicator of ill health for 1 person.” from the report
Kind interactions
Inspectors observed staff treating people warmly and supporting their choices in everyday routines.
“We observed positive interactions between people and staff.” from the report
Safe recruitment
The recruitment records reviewed showed that required safety checks were being followed.
“Staff files we looked at showed safe recruitment practices were followed.” from the report
Pressure mattress settings
seriousSome pressure-relieving mattresses were set incorrectly for people's weights. This created a risk of harm, although inspectors found no evidence that anyone had been harmed.
“Pressure mattress settings were not set correctly which placed people at risk.” from the report
Night-time routines
needs fixingPeople reported being expected to go to bed before night staff came on duty. Some people also said night workers were unhappy when they used their call bells.
“We have to be in bed before the night staff come on.” from the report
Capacity and consent records
needs fixingRecords did not always show people's capacity and consent accurately. A required assessment about covert medicines was not in place for one person.
“The recording of capacity and consent required improvement.” from the report
Rehabilitation information
needs fixingStaff did not receive updates from physiotherapy sessions, making it harder for them to support people's rehabilitation consistently.
“Staff told us they did not get updates from physiotherapy sessions, which was important to enable them to support people in the most appropriate way.” from the report
Oversight and feedback
minorThe home's checks did not identify every shortfall. Survey results were combined across the company, so the home could not see its own feedback clearly or respond to people who completed it.
“Gaps were found in identifying shortfalls in some quality standards.” from the report
- 01How do you now check that each person's pressure mattress is set correctly for their current weight?
- 02Can residents choose when to go to bed, and what night staffing levels are now in place?
- 03How do you record capacity and consent for people who may need covert medicines?
- 04How are physiotherapy instructions passed to care staff after each session?
- 05How do you collect and act on feedback specifically about this home?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and their previous ratings were used in calculating the overall rating. This explanation was written from the published report of 15 March 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 Requires Improvement; inspectors found kind and respectful care, but gaps in care records, risk management, medicines and oversight.
Inspectors visited unannounced on 24 October, 28 October and 1 November 2019. They spoke with five people, four relatives, seven staff and two visiting professionals. They also reviewed care records, medicines records, staff files and management records.
The home cared for 19 people at the time, although it could support up to 26. People and relatives spoke positively about the kindness, compassion and respect shown by staff. People felt safe, enjoyed the food and activities, and were supported to make choices and stay independent.
However, care plans and daily records were not always complete or consistent. Risk assessments, medicines records, staff training records, accident records and quality checks also needed improvement. The home had not notified CQC about all significant incidents, and two regulations were breached.
The overall rating was Requires Improvement. Safe, Effective, Responsive and Well-led were rated Requires Improvement, while Caring was rated Good. This was the first inspection since the provider changed on 6 August 2019, but the overall rating remained the same as at the previous inspection.
Kind and respectful staff
People and relatives spoke positively about staff. Inspectors found that privacy, dignity, choice and independence were supported.
“People told us they were treated with dignity and respect and their privacy was protected.” from the report
People involved in activities
People helped choose activities and were involved in recruiting the new activities coordinator. The report describes more outings and activities outside the home.
“A new activities coordinator had been appointed and people at the service were involved in their recruitment and had chosen the person they wanted.” from the report
Safe recruitment
Checks were carried out before staff were employed. People living in the home were involved in recruiting staff.
“Staff were recruited safely, and all the appropriate checks were carried out to protect people from the employment of unsuitable staff.” from the report
Support from health professionals
Staff worked with external professionals to meet people's health needs. Inspectors gave the example of someone being supported to attend an emergency dental appointment.
“The service worked closely with other health and social care professionals to ensure people received consistent and timely care.” from the report
Adapted equipment
Bathrooms had assistive equipment and bedrooms had overhead tracking hoists to support moving and handling.
“Bathrooms had been adapted to a high standard with assistive equipment and bedrooms had overhead tracking hoists to support safe moving and handling.” from the report
Care records were not reliable
seriousStaff did not always record important care, including positional changes and oral hygiene. This meant the home could not show that care had been provided each time.
“Due to the lack of accurate records, there was a risk people had not received the care they required.” from the report
Risk and incident management
seriousSome risk assessments lacked essential information. Accidents and near misses were not always recorded, and the home did not consistently investigate their underlying causes.
“A deeper analysis was needed to get to the root cause and really understand what had gone wrong.” from the report
Medicines management
needs fixingThere were inconsistent records for creams, variable-dose medicines and reasons for not giving medicines. Some medicines were temporarily out of stock, and some instructions for as-needed medicines were not clear.
“We found some issues with the management of medication, mainly in the consistency of recording.” from the report
Training and agency staff
needs fixingThe training record did not show that staff had completed all necessary training. More detailed checks were needed on temporary agency staff's training and competence, following several incidents and near misses.
“Due to the complexity of the needs of people at the service, improvements need to be made in the induction and competence checks on temporary staff.” from the report
Weak quality oversight
seriousAudits did not always identify problems or show that actions had been completed. The provider had also failed to notify CQC about all significant incidents.
“CQC had not been notified of all significant events such as several safeguarding incidents.” from the report
- 01What changes have been completed to make sure positional changes, oral hygiene and other care interventions are recorded every time?
- 02How are risks, accidents and near misses now reviewed to identify their underlying causes and prevent them happening again?
- 03How do you check temporary agency nurses and other agency staff have the right training and competence for people's complex needs?
- 04What has been changed in medicines management, including records for creams, variable-dose medicines and as-needed medicines?
- 05What action has been taken to improve audits and ensure problems are followed up and reported to CQC when required?
This was an unannounced planned inspection based on the previous rating and covered all five key questions; it was the first inspection since the provider changed on 6 August 2019. This explanation was written from the published report of 3 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.
Every inspection of Kenmore
5 rated inspections over 6 years: the service has held its Requires improvement rating throughout.
- March 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- November 2018Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2018Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- January 2017Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- July 2019
Registered with the Care Quality Commission on 31 July 2019.
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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
At least 100 live-in carers within about an hour of Kirklees
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,260 a week. 86 can care for a couple. 11 years' experience on average.
“Carla has been a god send with the implementation of bringing mum back home from respite care.”
“Primrose is a very kind and compassionate healthcare professional”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.