CQC report explained · a nursing home
What the CQC found at Kentford Manor
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People felt safe and medicines, recruitment and safety checks were generally managed properly. Inspectors raised concerns about some staff not washing or sanitising their hands between medicines support and some staff wearing false or painted nails.
- Effective?
- Good
- Staff were trained and supported, people's nutritional needs were met and staff worked with health professionals. Inspectors said the mealtime experience could be improved and some areas needed redecorating.
- Caring?
- Good
- People and relatives described staff as kind, patient and respectful. Staff supported people's choices, privacy, dignity and independence.
- Responsive?
- Good
- The home offered personalised support, activities and a complaints process. However, care plans were not always personalised and end of life plans did not consistently explain people's wishes.
- Well-led?
- Requires improvement
- Quality assurance and governance systems had not been effective enough to identify and resolve important issues. Leadership had been inconsistent during management changes, and there was no registered manager in post.
What inspectors found, January 2023
Kentford Manor was rated Good overall; inspectors found kind, safe care but weaknesses in leadership and care records.
The inspection was unannounced and took place on 28 November and 13 December 2022. Inspectors spoke with people living in the home, relatives and staff. They observed care and checked care plans, medicines records, recruitment files, training records and quality checks.
The home was rated Good for Safe, Effective, Caring and Responsive. People generally felt safe and said staff were kind, respectful and caring. Inspectors found enough staff overall, safe medicines arrangements, suitable training, good support with food and drink, activities and access to health professionals.
The home was rated Requires Improvement for Well-led. Quality checks had not found or fixed some problems, including gaps in care plans, end of life plans, hydration records and infection control practice. There was no registered manager in post during the inspection, and staff described leadership as inconsistent.
Kind and respectful care
People and relatives spoke positively about staff. Inspectors observed caring and compassionate support, with staff respecting privacy and personal choices.
“During our inspection visit we observed staff delivering caring and compassionate support to people at the service.” from the report
Safe medicines
People received medicines as prescribed. Staff administering medicines were trained and checked as competent, and medicines were stored safely.
“Medicines were managed safely; people received their medicines as prescribed.” from the report
Activities and social life
People could choose from a varied programme of activities and outings. Relatives were also positive about the opportunities available.
“There are lots of entertainments to choose from, there is a weekly programme.” from the report
Good partnership working
Staff worked with a range of outside health professionals to support people's health needs and outcomes.
“Staff worked in effective partnership with a wide range of external professionals to ensure people received the support they needed.” from the report
Weak quality checks
needs fixingThe home's monitoring systems did not consistently identify or fix problems. Issues with care plans, end of life plans, hydration and infection control had remained unresolved.
“The quality assurance systems were not sufficiently robust, and the governance was not always fully effective.” from the report
Care and end of life records
needs fixingSome care plans did not clearly describe people's preferences or the care they needed. End of life plans lacked meaningful information about people's wishes, including for one person receiving end of life care.
“People's care plans were not always person centred and did not consistently detail the care and support they wanted or preferred.” from the report
Infection control practice
needs fixingInspectors saw staff helping people with medicines without washing or sanitising their hands between people. Some staff were also wearing false or painted nails, creating an infection control risk.
“We observed staff assisting people with their medicines with no handwashing or hand sanitiser use between.” from the report
Leadership arrangements
needs fixingThere was no registered manager during the inspection. Staff described an inconsistent approach after management changes, and the home had not yet resolved issues identified by its own audits.
“At the time of our inspection there was not a registered manager in post.” from the report
Staffing pressure
needs fixingAlthough inspectors found enough staff overall, many staff said there were times when staffing was not sufficient to meet needs promptly. The home was using agency staff while recruiting permanent staff.
“There are days when there are insufficient staff numbers to fully ensure residents receive the care and support, they need.” from the report
- 01Who is currently responsible for managing the home while a registered manager is being recruited?
- 02How are you making sure each person's care plan reflects their preferences and current needs?
- 03How are end of life wishes recorded, reviewed and shared with staff and families?
- 04What has changed to make sure staff follow handwashing rules and do not wear false or painted nails?
- 05How are you monitoring staffing levels and reducing reliance on agency staff?
This was the first inspection of the newly registered service and covered all five CQC questions, including infection prevention and control under Safe; the previous provider's rating was Good in May 2020. This explanation was written from the published report of 17 January 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, May 2020
Kentford Manor rated Good; inspectors found kind, personalised care and safe systems across all five areas.
This was an unannounced, planned inspection on 21 February 2020. Inspectors spoke with 12 people living there, eight relatives and staff. They also observed care and checked care plans, medicines records, complaints, accidents, training and quality checks.
The inspectors found people were safe and received effective care. There were enough staff, medicines were managed safely, the home was clean, and staff had the training and skills needed. People were supported with food, drink, healthcare and decisions about their care.
Care was described as kind, respectful and personalised. People had activities and support suited to their interests. Relatives felt involved and said the home was well managed. All five areas were rated Good, the same as at the previous inspection published on 1 September 2017.
Kind and personal care
Staff took time to understand people's histories, preferences and emotional needs. Inspectors saw strong relationships between people and staff.
“People knew they were important and well cared for because the staff took time to understand and get to know them” from the report
Dignity and independence
People were involved in decisions and supported to remain independent. Staff respected privacy and adapted support to individual needs.
“People were supported and treated with dignity and respect; and involved as partners in their care.” from the report
Safe staffing and medicines
Inspectors found enough staff to meet assessed needs. Medicines were administered, recorded and checked safely.
“There were consistently enough staff to meet people's assessed needs.” from the report
Personalised activities and communication
People had activities based on their interests, including one-to-one support. Communication needs were assessed and supported through different formats.
“People were supported to enjoy a wide range of activities and told us they had made friends” from the report
Good management checks
Senior staff met daily and used audits, meetings and reviews to monitor safety and quality. Relatives said managers made time to speak with them.
“Systems to monitor the quality of service were in place which included reviewing care plans, checking medicines management, health and safety and the environment.” from the report
Call bell waits
minorOne person said they usually had to wait after pressing the call bell, although staff came reasonably quickly. Ask how response times are monitored for people who need urgent help.
“You usually have to wait when you press the bell, but they do come reasonably quickly.” from the report
- 01How quickly do staff usually respond to call bells, and how do you check this?
- 02How will you make sure my relative's risk assessments and care plans are kept up to date?
- 03How will you involve my relative and our family in reviewing their care and choices?
- 04What activities and one-to-one support would be available for my relative's interests and communication needs?
- 05How would you tell us about any accident, incident or change in my relative's care?
This was an unannounced, planned inspection covering all five key questions and the overall quality and safety of care. This explanation was written from the published report of 7 May 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 Kentford Manor
2 rated inspections over 3 years: the service has held its Good rating throughout.
- January 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2020GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2018
Registered with the Care Quality Commission on 8 June 2018.
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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