CQC report explained · a residential care home
What the CQC found at Kibworth Court
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found systems to protect people from abuse and manage risks. Medicines, staffing levels and infection control were generally handled safely, although staffing records did not clearly show all actual changes.
- Effective?
- Good
- People's needs were assessed before they moved in. Staff were trained, people's health and nutrition were supported, and consent and best-interest processes were followed.
- Caring?
- Good
- The report does not give a rating or detailed findings for Caring.
- Responsive?
- Good
- The report does not give a rating or detailed findings for Responsive.
- Well-led?
- Good
- Inspectors found approachable management, quality checks and systems for using feedback to improve the service. The home was described as consistently managed and well-led.
What inspectors found, January 2023
Kibworth Court rated Good; inspectors found safe, effective and well-led care, with some staffing record and agency supervision issues.
Inspectors visited without notice on 22 November 2022. They spoke with people, a relative and staff. They reviewed care plans, medicines, recruitment files, training records and management records.
The home was rated Good overall. Safe, Effective and Well-led were each rated Good. Inspectors found people were protected from abuse, received medicines safely, had enough staff to meet their needs and were supported with food, healthcare and decision-making.
There were some areas to improve. The staffing system did not clearly record actual day-to-day changes, and some regular agency staff had limited formal supervision. The home had previously been rated Requires Improvement, but Safe and Well-led improved to Good at this inspection.
Protection from harm
Staff knew how to identify and report abuse. Risks were assessed and guidance was in place to help staff keep people safe.
“There were systems and processes in place to safeguard people from potential harm.” from the report
Safe medicines
Medicines were stored, administered and recorded safely. Staff were trained and their competency was checked.
“People's medicines were stored, managed and administered safely.” from the report
Health and nutrition
People were supported with food, drinks, healthcare appointments and oral healthcare where needed.
“People were supported to maintain their health and were referred to health professionals such as the local GP, district nurses and chiropodists.” from the report
Open management
People, relatives and staff could share their views. Inspectors found that feedback was used to make improvements.
“People's voice was used to drive improvements in the service.” from the report
Staffing records
needs fixingThe electronic rota did not clearly show actual day-to-day staffing changes, including agency cover and unplanned absences. Management said it would improve the system.
“These records did not provide a clear audit trail on actual day to day staffing changes, such as agency and unplanned absence.” from the report
Agency staff supervision
needs fixingSome regular agency staff said formal supervision and feedback were limited. Management said it would provide more formal support.
“However, some regular agency staff felt this was limited.” from the report
- 01How do you now record actual daily staffing, including agency staff and unplanned absences?
- 02What formal supervision and feedback do regular agency staff receive?
- 03How will you keep my relative safe if there is a COVID-19 or other infection outbreak?
- 04How are my relative's individual choices, communication needs and activities recorded and reviewed?
- 05What improvements have been made since the previous Requires Improvement rating?
This inspection reported ratings for Safe, Effective and Well-led; it did not provide ratings or detailed findings for Caring or Responsive. This explanation was written from the published report of 20 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, February 2022
Inspected but not rated; improvements were found after previous concerns, but cleaning standards were still inconsistent.
This was an unannounced targeted inspection on 12 January 2022. Inspectors looked at infection prevention and control, visiting arrangements and how the home was managed. They spoke with three people and three staff, met the provider, and checked the building, cleaning records, audits and other documents.
The home had improved its maintenance, cleanliness and infection control. Staff used protective equipment properly, testing and visiting arrangements were in place, and repairs were completed promptly. However, some rooms still had dirt, dust and cobwebs, showing that cleaning was not consistent.
The provider had improved its checks and was no longer in breach of Regulations 12 or 17. However, this was a targeted inspection, not a full review. The Safe and Well-led ratings were therefore not changed and remained recorded as Requires Improvement from the previous inspection, although this report itself says inspected but not rated.
Infection control
Staff used protective equipment appropriately and the home had enough supplies. Testing, isolation arrangements and infection outbreak plans were in place.
“We were assured that the provider was using Personal Protective Equipment (PPE) effectively and safely.” from the report
Maintenance
The home had improved its maintenance arrangements, replaced mattresses and bedding, and completed repairs promptly.
“Repairs were undertaken in a timely way to ensure the environment was safe for people.” from the report
Improved oversight
The provider had developed regular audits and checks across areas such as medicines, care plans and infection control. The previous governance breach had been addressed.
“Enough timely action had been taken and the provider was no longer in breach of regulation 17.” from the report
Inconsistent cleaning
needs fixingSome people's rooms and the laundry had dirt, dust and cobwebs. Inspectors said cleaning standards were not consistently embedded in staff practice.
“Although we found improvements in overall standards of housekeeping, evidence showed these were not consistent in staff working practices.” from the report
Cleaning checks
needs fixingThe cleaning audits did not reliably identify all areas where standards were inconsistent. The provider said further work was already under way.
“Audits and checks of cleaning standards were not always effective and required further development.” from the report
- 01How do you check that every bedroom, the laundry and other areas are cleaned consistently?
- 02Who completes the cleaning checks, and how do you make sure those checks cover all rooms?
- 03What changes have been made since the inspection to ensure cleaning standards stay consistent?
- 04How will you monitor the improvements until the next comprehensive inspection?
- 05How will visits, testing and protective equipment arrangements be managed if there is another infection outbreak?
This was a targeted inspection of infection prevention and control and well-led arrangements, so the Safe and Well-led ratings were not changed and the other key questions were not assessed. This explanation was written from the published report of 10 February 2022 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 Kibworth Court
5 rated inspections over 7 years: the service has improved, from Requires improvement to Good.
- January 2023Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2022Inspected but not ratedSafe: Inspected but not ratedWell-led: Inspected but not rated
- September 2021Requires improvementSafe: Requires improvementWell-led: Requires improvement
- January 2021Inspected but not ratedSafe: Inspected but not rated
- January 2018Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Good
- December 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- August 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- July 2014
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- September 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 27 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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