CQC report explained · a residential care home
What the CQC found at Kensington Lodge
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Some risks were not assessed accurately or consistently with care plans, including choking and malnutrition risks. Staffing, safeguarding, medicines and several infection control arrangements were found to be safe, with some improvements since the previous inspection.
- Effective?
- Good
- This key question was not inspected during this focused visit. Its previous rating was carried forward.
- Caring?
- Good
- This key question was not inspected during this focused visit. Its previous rating was carried forward.
- Responsive?
- Good
- This key question was not inspected during this focused visit. Its previous rating was carried forward.
- Well-led?
- Requires improvement
- Management checks did not reliably identify inaccurate records, unsecured confidential information, food recording gaps or environmental issues. The home remained in breach of Regulation 17 for good governance.
What inspectors found, April 2023
Kensington Lodge rated Requires Improvement; inspectors found kind, safe support in many areas, but risk records and management checks were not reliable enough.
This was an unannounced follow-up inspection on 23 March 2023. Inspectors checked whether the home had acted on problems found at the previous inspection. They observed care, spoke with people, relatives, staff and health professionals, and checked care, medicine, recruitment and management records.
The home had enough trained staff, and people said they felt safe and were treated kindly. Medicines were generally given safely, infection control had improved, and staff knew people well. Care plans were detailed and staff worked with health professionals.
However, some health risk assessments did not match care plans or people's circumstances. Food intake was not always recorded properly for a person at risk of malnutrition. Records were not always stored securely, and audits did not reliably find problems. The home remained in breach of Regulation 17, so the overall rating stayed Requires Improvement.
Enough trained staff
Inspectors found enough staff to meet people's needs. Staff were safely recruited, trained and observed to be unhurried and available to help.
“There were enough trained and competent staff to support people.” from the report
Kind and personal care
People and relatives described staff as kind and approachable. Staff knew people's preferences and responded to their needs promptly.
“People's care plans were detailed, person-centred and included information which was important to them.” from the report
Medicines improved
Staff were trained and assessed as competent to give medicines. Storage, ordering and disposal were safe, although two creams were not dated.
“Staff were trained and assessed as competent before being permitted to administer medicines to people.” from the report
Good partnership working
Staff worked with health and social care professionals and followed professional advice to support people's care and wellbeing.
“The staff and management team worked effectively with professionals.” from the report
Governance breach
seriousThe home remained in breach because records were not securely stored and quality checks did not identify important shortfalls. The provider had been told to improve this after the previous inspection.
“The provider had failed to maintain records securely. Quality assurance systems had not identified shortfalls in records including for the monitoring and management of risks.” from the report
Inaccurate risk assessments
seriousSome risk assessments did not match care plans or professional advice. This included choking and malnutrition risks, although staff knew people's needs and one record was updated after inspectors raised the issue.
“Risks were not always accurately assessed to promote people's safety.” from the report
Food intake records
needs fixingFood intake was not consistently recorded for a person at high risk of malnutrition and with changing weight. This meant records did not always show what the person had eaten.
“Staff had not consistently recorded what they had eaten.” from the report
Infection control checks
needs fixingCleaning records did not clearly list all equipment needing sanitation. Inspectors also found equipment needing deep cleaning and a face-mask policy that did not reflect current guidance.
“The service was clean; however, we identified a piece of equipment which required deep cleaning.” from the report
- 01How have you made sure risk assessments now match care plans and professional advice, especially for choking and malnutrition?
- 02How are you recording food and drink for people whose weight or nutrition is a concern?
- 03Where are confidential care records stored now, and who checks that they remain secure?
- 04How do your audits confirm that medicines are dated correctly and that all equipment is cleaned as required?
- 05What actions are included in your current plan to address the continued Regulation 17 breach, and what progress has been made?
This was a focused follow-up inspection of Safe and Well-led only; the other key question ratings were carried forward from the previous inspection. This explanation was written from the published report of 20 April 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, November 2021
Rated Requires Improvement; inspectors found infection, medicines and record-keeping problems, although staff were caring and there were enough staff.
This was an unannounced inspection on 15 October 2021 after concerns about infection control. One inspector spoke with people, relatives and staff, observed care, and checked care, medicines, recruitment and management records.
The home was not always safe. Staff were not wearing masks in communal areas when inspectors arrived. Some medicines did not have opening dates, and the medicines trolley temperature was not checked. These issues were dealt with during or shortly after the inspection.
Inspectors also found confidential records left in a communal lounge and incomplete food and fluid records. The provider's audits had not found all these problems. This led to a breach of Regulation 17 on good governance.
The overall rating changed from Good at the last inspection, published in August 2019, to Requires Improvement. Only Safe and Well-led were inspected this time. The other areas were not inspected and earlier ratings were used in the overall rating.
Enough staff
Inspectors found enough staff to meet people's needs. Staff acted promptly when people needed support, and agency staff were rarely used.
“There were sufficient staff on duty to meet people's needs.” from the report
Kind and patient care
People appeared comfortable with staff. Staff involved people in choices and supported people living with dementia with patience and understanding.
“We observed staff engaging and involving people in all aspects of their care.” from the report
Safe recruitment
The recruitment record checked included the required criminal-record check, employment history and references.
“New staff were recruited safely.” from the report
Risk assessments
Inspectors found that risks such as nutrition, moving and handling, weight and some health conditions were identified and managed.
“Risks were identified, assessed and managed safely.” from the report
Masks were not always worn
seriousWhen inspectors arrived, staff were not wearing masks in communal areas where people were present. Inspectors said this put people and staff at risk of infection.
“Staff were not wearing masks when working or supporting people in communal areas of the home.” from the report
Medicines checks
needs fixingSome creams and liquid medicines did not show when they had been opened. The temperature inside the medicines trolley was also not monitored.
“Some medicines such as oral suspensions and topical creams had been opened, but the date they had been opened was not recorded on the medicine itself.” from the report
Poor record security and accuracy
seriousConfidential medicines information was left in an open box in a communal lounge. Some food and fluid records were incomplete, and audits had not identified these problems.
“The provider had failed to maintain records securely. Records relating to risk management contained incomplete information and were not maintained accurately.” from the report
Privacy during personal care
needs fixingOne person was given topical cream in the conservatory without enough privacy or dignity. The manager later reminded staff to use a screen or move the person to a private area.
“There was no privacy for the person and the manner in which the staff member treated them was not dignified.” from the report
- 01How do you now check that staff wear masks in communal areas and follow current infection-control guidance?
- 02How are medicine opening dates recorded, and how is the medicines trolley temperature checked each day?
- 03How are confidential medicines records and other personal information kept secure now?
- 04How do you check that food and fluid records are complete and show people's recommended daily intake where needed?
- 05How do staff protect people's privacy when applying creams or providing other personal care?
This was a focused inspection of Safe and Well-led after an infection-control concern; Effective, Caring and Responsive were not inspected and their previous ratings carried over. This explanation was written from the published report of 18 November 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.
Every inspection of Kensington Lodge
4 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- April 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- August 2019Goodstayed GoodSafe: GoodWell-led: Good
- December 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2014
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- June 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 26 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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