CQC report explained · a residential care home
What the CQC found at Kenrick Centre
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, December 2019
Rated Requires Improvement; inspectors found kind and responsive care, but risks and management systems were not always handled reliably.
This was an unannounced inspection on 30 October and 04 November 2019. Inspectors spoke with people, relatives and staff, observed care and reviewed care, medicine and management records.
The home had improved since its previous inspection in March 2019, when it was rated Inadequate and placed in special measures. Medicines, infection control, staff training and activities had improved. People were generally treated with kindness, dignity and respect.
However, risk assessments and care records were not always updated or clear. Staff did not always follow health professional instructions consistently, and some discussions about people's consent and care were not recorded. The overall rating was Requires Improvement, with Safe, Effective and Well-led also rated Requires Improvement. Caring and Responsive were rated Good.
Safer medicines
Inspectors found that medicines were being managed safely. Storage, temperature checks, timing and support for people managing their own medicines had improved.
“At this inspection we found that the required improvement had been made and medicines were managed safely.” from the report
Kind and respectful staff
People and relatives said staff were kind. Inspectors saw staff having positive conversations, protecting privacy and encouraging independence.
“We observed positive interactions between staff and people. Staff smiled at people, had meaningful conversations and gave people compliments to boost their self-esteem.” from the report
Improved activities
The home had introduced more social events, trips and activities, including baking and cookery sessions. People could also use facilities in the wider centre.
“Some social events had taken place, trips out in the local community and improvements had been made to in house activities.” from the report
Better staff training and support
Training opportunities, supervision and observed practice had improved since the previous inspection. Staff said they could discuss learning and request further training.
“Improvements had been made to the training and development of the staff team.” from the report
Risk records were not reliable enough
seriousSome risk assessments were unclear, not specific enough or not updated after incidents or changes in need. Instructions from health professionals were not always followed consistently.
“We found no evidence that people had been harmed however, systems were not always robust enough to demonstrate risks to people were effectively managed.” from the report
Consent records were incomplete
needs fixingStaff usually offered choices, but records did not always show how people had been consulted about their care or what had been agreed. Staff also had limited understanding of mental capacity.
“Where MCA assessments had been completed, for some people how staff had consulted with people about their care and the outcome of these discussions had not always been recorded.” from the report
Management checks needed to improve
seriousThe home's quality systems did not consistently identify risks or make sure improvements were sustained. This had been a repeated concern across recent inspections.
“This demonstrated that the registered provider's systems in place to review quality were not always effective enough to drive the improvements in the service.” from the report
Some people wanted more activities
minorActivities had improved, but some people said they would like more things to do during the day.
“However, some people told us further improvements were needed and they would like more things to do in the day to keep them occupied.” from the report
- 01How will you make sure risk assessments are updated immediately after an accident, hospital visit or change in someone's needs?
- 02How do you check that staff follow health professional instructions consistently and escalate concerns promptly?
- 03How do you assess mental capacity, involve people in decisions and record what they have agreed?
- 04What quality checks are now in place to show that improvements are lasting and that risks are acted on?
- 05What activities are available each day for people who want more to do?
This was a planned, unannounced inspection covering all five CQC questions, including the care and premises; it followed the previous Inadequate rating and reviewed improvements since March 2019. 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.
What inspectors found, August 2019
Rated Inadequate and placed in special measures; inspectors found serious safety and management failures despite some kind and supportive care.
Inspectors visited over three days in March 2019. The inspection was unannounced at first and covered both units. They reviewed care and medicines records, audits and meeting notes, and spoke with people, relatives, staff, managers and a social worker.
They found that people were at risk because some health and behaviour risks were not recorded clearly or managed consistently. Medicines were not always stored or given safely. Infection control, staff training, care records and learning from incidents also needed improvement.
People generally said they felt safe, and inspectors found enough staff, kind communication, support for independence and access to health professionals. However, the overall rating was Inadequate because the Safe and Well-led areas were Inadequate. Effective, Caring and Responsive were all rated Requires Improvement.
Enough staff
Inspectors found enough staff to meet people's assessed care and support needs. Recruitment checks were also described as robust.
“There were sufficient numbers of staff at Kenrick Centre to assist people with their care and support needs.” from the report
People felt safe
People told inspectors they felt safe with the staff supporting them. Staff had safeguarding training and knew how to respond to concerns.
“People told us they felt safe living at Kenrick Centre and when staff supported them.” from the report
Support for independence
Staff encouraged people to make choices and do things for themselves where possible. People could choose where to eat and where to spend their time.
“Staff encouraged and supported people to be as independent as possible.” from the report
Access to health professionals
People could see health professionals, and the enablement unit held weekly meetings to review progress and care needs.
“People had access to health professionals such as district nurses.” from the report
Supportive communication
Inspectors observed staff communicating warmly with people. Staff knew people's preferred ways of communicating and helped them make choices.
“Staff communicated with people in a warm and friendly manner.” from the report
Unsafe medicines management
seriousMedicines were not always stored or administered safely. Fridge temperatures were not checked correctly, some instructions were missing, and one person reported becoming ill after being given the wrong instructions.
“Medicines were not always managed and administered safely in the residential unit of the home.” from the report
Infection control shortfalls
seriousStaff did not always use protective clothing or wash their hands between tasks. Some bins also had no lids, increasing the risk of infection and cross-contamination.
“Staff did not always follow best practice and guidance when supporting people to prevent the spread of infection and cross contamination.” from the report
Training was out of date
needs fixingSome staff had not received refresher training for important conditions and legal requirements. This included epilepsy, dementia and the Mental Capacity Act.
“Staff did not always receive additional or regular refresher training following their induction, for some recognised health conditions, changes in legislation and best practice guidance.” from the report
Privacy and dignity
needs fixingInspectors saw some staff enter rooms without always knocking. On one occasion, a person was supported to use the toilet with the door left open.
“On one occasion we saw a person being supported to go to the toilet, and care staff left the door open whilst they supported them.” from the report
Limited activities
needs fixingAlthough some activities were available, several people said there was not enough to do and that they were bored or left alone with television or reading.
“There's nothing to do at all here. At night we can only watch TV. I'm often bored.” from the report
- 01What has changed in medicines storage, fridge-temperature checks and instructions for as-required or patch medicines since this inspection?
- 02How are risks such as epilepsy, choking, falls and mobility now recorded and checked in daily care?
- 03Which staff have completed refresher training in dementia, epilepsy and the Mental Capacity Act, and how is this monitored?
- 04How are care records kept current, including mental capacity assessments, best-interest decisions and details of representatives or advocates?
- 05What activities are now available for people who are bored or do not want to spend their time watching television or reading?
This was an unannounced comprehensive inspection of both care units, including care and accommodation, but it did not inspect the café, gym or day centre facilities because CQC does not regulate those services. This explanation was written from the published report of 10 August 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 Kenrick Centre
6 rated inspections over 5 years: the service has held its Requires improvement rating throughout.
- December 2019Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2019Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- January 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2015Requires improvementstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- February 2014
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- February 2012
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 23 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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