CQC report explained · a nursing home
What the CQC found at Kenwyn
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from avoidable harm, and risks were assessed with clear guidance for staff. Medicines, recruitment, equipment, emergency arrangements and infection control were managed safely.
- Effective?
- Good
- People's needs were assessed and reviewed, and staff had the skills and training to provide effective care. People were supported with food, fluids, healthcare and decisions about their care.
- Caring?
- Good
- This key question was not inspected during this focused visit. Its previous rating was used in calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this focused visit. Its previous rating was used in calculating the overall rating.
- Well-led?
- Good
- Managers had improved the culture since the previous inspection. Staff, relatives and healthcare professionals described the management as supportive, approachable and communicative.
What inspectors found, June 2021
Kenwyn was rated Good; inspectors found safe, effective and well-led care, with improvements since the previous inspection.
This was an unannounced focused inspection on 12 and 14 May 2021. Inspectors looked at Safe, Effective and Well-led. They spoke with people, staff, managers, healthcare professionals and relatives. They reviewed care records, medicines records, recruitment files and other management records.
Inspectors found enough staff to meet people's needs, although short-notice sickness sometimes meant staffing was lower than planned. Staff were moved between units to maintain the right skills. Medicines, care plans, risk assessments and infection control were managed well.
People received care from trained staff who understood their needs. Staff supported people to access healthcare, eat and drink enough, and make decisions where possible. Managers were described as approachable, honest and open, and systems were in place to monitor and improve the home.
The overall rating improved from Requires Improvement to Good. Caring and Responsive were not inspected on this visit, so their previous ratings were carried forward into the overall rating.
Staffing and continuity
There were enough staff to meet people's needs, and staff were allocated to specific units. The home had not used agency staff since the start of the pandemic.
“There were sufficient staff employed to meet the needs of the people who used the service.” from the report
Care planning
Care plans and risk assessments were current and gave staff clear instructions about people's individual needs and known risks.
“Care plans were comprehensive and provided staff with clear guidance about how to provide the right care and support for people.” from the report
Medicines
Inspectors found suitable arrangements for ordering, storing, giving and disposing of medicines. Staff also arranged reviews of medicines that might need regular review.
“People received their medicines safely and in the way prescribed for them.” from the report
Management culture
The report found a more open and trusting culture than at the previous inspection. Staff and relatives said managers listened and communicated well.
“At this inspection we found there was a positive culture within the staff team and staff told us they felt supported by the management team.” from the report
Short-notice sickness
minorStaff said staffing levels were sometimes lower than planned when people were unexpectedly off sick. The home responded by moving staff between units and inspectors found the right skill mix was maintained.
“Staff told us there were occasions when staffing levels were lower than planned, when short notice sickness occurred.” from the report
One-to-one supervision
needs fixingStaff had group supervision and some individual sessions, but one-to-one meetings had not happened as often as planned. Managers said they would create a more even spread of supervision types.
“The number of one-to-one sessions, where staff could discuss their own work and reflect on their practice, had not been as frequent.” from the report
- 01How do you cover short-notice sickness, and how do you make sure each unit has the right staff skills?
- 02How often will my relative's carers have one-to-one supervision and discuss their practice?
- 03What was the previous rating for Caring, and what evidence supports that rating now?
- 04How will you involve relatives in care plan reviews and gather their feedback?
- 05How do you monitor medicines reviews, especially for sedative, anti-psychotic or antidepressant medicines?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and their previous ratings carried over into the overall rating. This explanation was written from the published report of 8 June 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.
What inspectors found, September 2019
Rated Requires Improvement; inspectors found kind, responsive care, but concerns about staffing, management and follow-through.
This was an unannounced inspection on 16 July 2019. Inspectors spoke with people, relatives, staff and a health professional. They reviewed care plans, medicines records, incidents, complaints, staff records and quality checks.
People were generally treated kindly and with dignity. Care plans were detailed and regularly updated. Medicines were managed safely, activities were available seven days a week, and records about mental capacity and restrictions were accurate.
However, staffing had been too low on some days. Some people did not receive support quickly enough. Staff morale was low, communication with managers was poor, and some training, appraisals and improvement actions had not been completed promptly.
The overall rating changed from Good to Requires Improvement. Safe stayed Requires Improvement, while Well-led fell from Good to Requires Improvement. Effective, Caring and Responsive were rated Good.
Kind and respectful care
Inspectors observed kind interactions. People said they felt respected, and personal care was provided privately.
“We observed kind and caring interactions between people and staff.” from the report
Safe medicines
Medicines were ordered, given, stored and monitored through suitable systems. Staff were trained and checked for competence.
“Medicines were safely managed. There were suitable systems in place for the ordering, administering and monitoring and disposal of medicines.” from the report
Personalised care plans
Care plans included people's needs, preferences and routines. They were reviewed and updated when people's needs changed.
“Care plans described people's individual needs, preferences and routines. Care plans were regularly reviewed and updated to ensure they reflected any changes in people's needs.” from the report
Activities and relationships
The home provided activities throughout the week, including one-to-one activities. People were supported to go outside and visitors were welcomed.
“There were four activity co-ordinator's who covered seven day a week throughout the service.” from the report
Accurate legal records
Records about Deprivation of Liberty Safeguards authorisations matched the local authority's records. Conditions attached to authorisations were being monitored.
“The records held of which people had DoLS authorisations tallied with the records held by the local authority DoLS team.” from the report
Staffing and response times
seriousStaffing was below planned levels on several occasions. People said they sometimes waited for help, including help to use the bathroom.
“People did not always get the support and care they needed in a timely manner.” from the report
Unsettled management
needs fixingThere had not been a consistent registered manager for over a year. Staff reported low trust, poor communication and feeling that their concerns were not acted on.
“The service had not had a consistent registered manager since February 2018.” from the report
Training shortfall
needs fixingSome staff supporting a person with complex needs had still not received the appropriate training at the inspection. The provider said this would be addressed immediately.
“At this inspection we found this concern remained.” from the report
Dementia unit condition
needs fixingThe dementia unit had not been refurbished as planned. Inspectors found an odour and said the area needed redecoration and new furnishings.
“There was an odour in this unit and the area was in need of re-decoration and new furnishings.” from the report
Slow improvement actions
needs fixingSome actions from audits had been carried forward and were not completed promptly. This meant opportunities to improve the service may have been missed.
“However, some actions had not been carried out in a timely manner.” from the report
- 01What staffing levels are now planned for each shift, and how do you cover sickness or staff leaving at short notice?
- 02How do you check that people are answered promptly when they use their call bells?
- 03What training has been completed for staff supporting people with complex needs?
- 04What has changed since the inspection to improve communication and trust between staff, managers, people and families?
- 05What work has been completed in the dementia unit, and how are outstanding audit actions tracked to completion?
This was an unannounced inspection covering the home, the care provided and all five CQC questions, prompted by concerns about staffing, care and management; the existing registration conditions remained in place. This explanation was written from the published report of 5 September 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 Kenwyn
7 rated inspections over 5 years: the service has held its Good rating throughout.
- June 2021Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2019Requires improvementdown from GoodSafe: Requires improvementEffective: GoodWell-led: Requires improvement
- November 2018Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2018
Location report published without a new overall rating.
- March 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- November 2016Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- September 2011
Report published without a new overall rating.
- February 2011
Registered with the Care Quality Commission on 15 February 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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Most charge £980 to £1,200 a week. 8 can care for a couple. 12 years' experience on average.
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