CQC report explained · a nursing home
What the CQC found at Kentwood House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Good
- Inspectors found that risks had been identified and managed, staff understood safeguarding, infection control was effective and medicines were managed safely. They noted that guidance about some health conditions could be more detailed.
- Effective?
- Requires improvement
- This question was not inspected during this visit. The rating was carried forward from the previous inspection.
- Caring?
- Good
- This question was not inspected during this visit. The report did describe kind, respectful and dignified interactions.
- Responsive?
- Good
- People received personalised support and had choices about their care, meals, activities and daily routines. Staff knew people's preferences and communication needs.
- Well-led?
- Requires improvement
- The provider was approachable and open to suggestions, but records still needed improvement. Inspectors were not assured that the registered manager provided the required daily oversight, and the home remained in breach of Regulation 17.
What inspectors found, May 2023
Rated Requires Improvement; safe and responsive care improved, but records and management oversight still needed work.
This was an unannounced focused inspection on 2 and 7 March 2023. Inspectors spoke with eight people, staff and the nominated individual. They observed care and reviewed care plans, medicines records and management records.
The home was rated Good for Safe and Responsive. Inspectors found that risks, staffing, medicines and infection control were managed safely. People described staff as kind, respectful and attentive. Care was more personalised than at the previous inspection.
The home was rated Requires Improvement for Well-led, so the overall rating remained Requires Improvement. Records were still not detailed enough in some mental capacity assessments and in guidance about specific health needs. The provider remained in breach of Regulation 17 about good governance.
Safer risk management
Risk assessments, equipment checks, incident records and infection control had improved. The previous breach relating to safe care and treatment had been resolved.
“Enough improvement had been made at this inspection and the provider was no longer in breach of regulation 12.” from the report
Kind and respectful staff
People said staff were kind, attentive and friendly. Inspectors saw staff supporting people politely, sensitively and with dignity.
“We observed caring, respectful and kind interactions between staff and people using the service.” from the report
Personalised support
People had choices about how they were cared for, what they ate and how they spent their time. Staff knew people's likes, dislikes and preferred routines.
“People were supported in a personal way by staff who knew people well, were aware of people's likes and dislikes and knew how people preferred to be supported.” from the report
Safe medicines practice
Medicines were stored securely and given safely by trained staff. Records included important information such as photographs and allergies.
“Medicines were managed consistently and safely in line with national guidance” from the report
Incomplete decision-making records
needs fixingSome mental capacity assessments did not explain clearly how decisions had been reached. The provider said these would be reviewed.
“Records regarding whether people could make decisions for themselves were not always complete.” from the report
Insufficient health guidance
needs fixingCare records needed more detail about conditions such as diabetes, anxiety and depression. This could make it harder for staff to know what signs to look for and how best to respond.
“They would benefit from more detailed guidance on specific conditions such as diabetes or information on signs and symptoms of depression or dementia” from the report
Weak management oversight
seriousThe registered manager was not present or available during the inspection. Inspectors were not assured that the manager was meeting regulatory responsibilities or providing daily oversight.
“We were not assured the registered manager was fulfilling their regulatory requirements and had daily oversight of the service.” from the report
Continuing governance breach
seriousThe provider had improved some records but had not done enough to make sure records were accurate and complete. This was a continuing breach of Regulation 17.
“Not enough improvement had been made at this inspection and the provider was still in breach of regulation 17.” from the report
- 01How will you make each mental capacity assessment decision-specific and record how the decision was reached?
- 02What new guidance will staff have for diabetes, anxiety, depression and dementia, and when will it be in place?
- 03Who provides daily management oversight when the registered manager is not at the home?
- 04What is the timetable for meeting the Regulation 17 action plan, and how will families be told about progress?
- 05How will you collect and act on feedback from residents, relatives and staff?
This was a focused inspection of Safe, Responsive and Well-led; Effective and Caring were not inspected and their ratings were carried forward from the previous inspection. This explanation was written from the published report of 17 May 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, January 2023
Kentwood House was rated Requires Improvement; inspectors found kind care and safe medicines, but serious gaps in risk management, personalised care and leadership.
This was an unannounced inspection on 5 October 2022. Inspectors spoke with eight people living there, 11 relatives and six staff. They observed care, checked records and reviewed medicines, recruitment, training, safety checks and audits.
The home was not always safe. Risk assessments were incomplete, some safety checks were not recorded, chemicals were accessible and an incident had not been recorded or investigated. Staff were not always available when people needed help. Medicines were managed safely, but infection control practice was not always reliable.
People were treated kindly and with dignity. However, care plans did not always reflect people's choices. People had limited opportunities for activities, food choices and baths or showers. Some rooms were cold and parts of the building needed repair.
The overall rating fell from Good at the previous inspection, published on 23 August 2018, to Requires Improvement. The provider was found in breach of Regulations 9, 12 and 17. CQC requested an action plan and said it would monitor progress.
Kind and respectful staff
People and relatives said staff were caring and knew people well. Inspectors saw staff protecting privacy and supporting independence.
“People were treated with dignity and respect; their privacy was protected, and they were encouraged to be independent where possible.” from the report
Medicines
Medicines were stored securely and administration records were completed accurately. People said they received medicines on time.
“Medicines were managed safely in line with national guidance.” from the report
Access to healthcare
Nurses understood people's healthcare needs and involved other professionals when needed. Hospital information was available if someone needed hospital care.
“Nurses had knowledge of peoples' healthcare needs and knew how to support them to achieve good outcomes.” from the report
Safeguarding knowledge
Staff had safeguarding training and knew how to recognise and report abuse. The manager had reported safeguarding concerns to the appropriate authorities.
“Staff had been trained and were knowledgeable about safeguarding.” from the report
Incomplete risk controls
seriousSome risks linked to bed rails, pressure-relieving mattresses, fire safety and chemicals were not properly assessed or controlled. This was linked to a breach of Regulation 12.
“Risk assessments had not consistently identified and managed risks to keep people safe.” from the report
Incidents not investigated
seriousAn incident described during the inspection had not been recorded or investigated. The home had no available accident and incident records.
“Accident and incident records were not available during our inspection.” from the report
Care was not personalised
seriousPeople did not always receive choices about washing, meals, drinks or how care was carried out. This was a breach of Regulation 9 and led to a warning notice.
“Not all care plans were personalised and people did not receive person centred care and support.” from the report
Little to do
needs fixingThere was no programme of activities and no activity staff. People were often bored and had limited social interaction.
“Most people told us there was not much to do and they were bored.” from the report
Weak quality monitoring
seriousAudits and care plan reviews did not identify problems found by inspectors. Records about care, staff training and competence were incomplete, which was a breach of Regulation 17.
“The provider did not have robust quality monitoring processes in place.” from the report
Cold rooms and repairs needed
needs fixingPeople's rooms were cold, some bathrooms did not have hot water, and parts of the building had worn or damaged finishes.
“People's rooms were cold and their bathrooms did not have hot water.” from the report
- 01What has been done to fix the risks involving bed rails, pressure-relieving mattresses, window restrictors, emergency lighting and accessible chemicals?
- 02How are incidents now recorded, investigated and used to prevent similar events?
- 03How do people choose their meals, drinks, bathing times and personal care arrangements?
- 04What regular activities are now available, and how are people's individual interests included?
- 05Have visiting times and appointment requirements changed since the inspection, and how can relatives visit at suitable times?
This was an unannounced inspection covering all five CQC key questions, including infection prevention and control measures. This explanation was written from the published report of 19 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.
Every inspection of Kentwood House
5 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- May 2023Requires improvementcurrent ratingstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2023Requires improvementdown from GoodSafe: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- August 2018Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2016Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- November 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 13 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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