CQC report explained · a residential care home
What the CQC found at Kimberley Care Village
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found people were protected from avoidable harm. Risk assessments, care records, staffing, recruitment, medicines, cleanliness and learning from incidents were all found to be managed safely.
- Effective?
- Good
- People's needs were assessed and staff had relevant training and support. Nutrition arrangements had improved, although people did not always have a choice of meal at the time of the inspection.
- Caring?
- Good
- People and relatives described staff as kind, respectful and welcoming. Staff asked permission before providing care and supported people's privacy, dignity and choices.
- Responsive?
- Good
- Care plans were detailed and personalised, and communication needs were recorded. Some people said they would like more activities and trips out.
- Well-led?
- Good
- Inspectors found strong systems for monitoring care, staff and the environment. However, the home had not told the CQC when some Deprivation of Liberty Safeguards authorisations had been renewed.
What inspectors found, March 2019
Rated Good; inspectors found kind, safe and well-managed care, with some gaps around activities, meal choices and notifications.
This was an unannounced inspection on 28 November 2018. Inspectors spoke with people living at the home, relatives, staff and a healthcare professional. They observed care and reviewed care plans, medicines records, staff recruitment files and quality checks.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People and relatives generally said staff were kind, friendly and trustworthy. Inspectors found enough staff, safe medicines management, personalised care plans, good links with healthcare professionals and effective systems for checking quality.
The home had improved since its previous Requires Improvement rating in July 2017. Inspectors found that earlier concerns about risk assessments, night care, medicines guidance, nutrition records and quality checks had been addressed. However, some people wanted more activities and more choice at mealtimes, and the home had not reported some renewed Deprivation of Liberty Safeguards authorisations to the CQC.
Kind and respectful staff
People and relatives described staff as friendly, caring and respectful. Inspectors found that people had built trusting relationships with staff.
“They are all nice to me and so friendly and they are kind to all of us.” from the report
Personalised care
Care plans covered people's physical, mental health and social needs. They included personal histories, preferences, communication needs and guidance on how to support each person.
“The care plans were highly individualised, personalised, holistic and thoughtful.” from the report
Safe medicines and risk management
Medicines were safely administered, stored and recorded. Risk assessments were comprehensive and staff used clear plans and checks to reduce identified risks.
“Medicines were safely administered. Staff who administered medicines had received training and had been observed to ensure that they were competent.” from the report
Improved food and nutrition support
The home had moved to fresh cooking and used specialist advice to support people at risk of malnutrition. Inspectors found that some people had improved enough to be removed from the malnutrition risk list.
“The provider had recently introduced home cooked food into the home and people told us that this had improved the quality of the food.” from the report
Effective leadership and checks
The registered manager and provider had strengthened audits and acted on concerns from the previous inspection. Staff said they felt supported and could raise concerns.
“At this inspection we found the governance framework was clear and strong.” from the report
Limited meal choice at the inspection
needs fixingPeople were not being offered a choice of meal at mealtimes. The home said this was temporary while staff adjusted to the new cooking arrangements, and that alternatives were available if people disliked the meal offered.
“People did comment that they were not getting offered a choice of food at mealtimes” from the report
Some people wanted more activities
minorSome people said there were few trips out and not much to do. Records showed that activities and one-to-one sessions were also provided.
“People told us they would like more activities provided.” from the report
Missed regulatory notifications
needs fixingThe home had reported new Deprivation of Liberty Safeguards authorisations but had not reported when some authorisations were renewed. The manager said this would be corrected in future.
“However, they had not told us about when people's Deprivation of Liberty Safeguards (DoLS) had been reauthorised.” from the report
Occasional short waits for help
minorPeople generally said staffing was sufficient, but one person said they sometimes waited around 10 minutes when two staff were needed.
“I do wait say 10 minutes sometimes because I need two to help me.” from the report
- 01What activities and trips are currently available for someone with my relative's interests and mobility?
- 02Can residents choose between meals, and what alternatives are offered if they do not like the main meal?
- 03How do you check that people who need two staff for moving or personal care do not wait too long?
- 04How are Deprivation of Liberty Safeguards authorisations and renewals recorded and reported?
- 05What improvements to the dementia unit refurbishment have been completed since this inspection?
This was an unannounced planned inspection covering all five CQC questions and the care home premises and care provided; the visit took place on 28 November 2018 and the report was published on 11 March 2019. This explanation was written from the published report of 8 March 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.
What inspectors found, July 2017
Rated Requires Improvement; inspectors found kind, responsive care, but gaps in safety, records and management.
Inspectors visited the home without notice on 28 February and 1 March 2017. They spoke with residents, visitors, staff and the manager. They observed care and checked five care plans, medicines, staffing, training and management records.
The home was rated Good for Caring and Responsive. People were treated kindly, supported to make choices and helped to stay independent. Care assessments were completed before people moved in, and complaints were investigated.
The home was rated Requires Improvement overall, and also for Safe, Effective and Well-led. Inspectors found gaps in skin-care planning, medicines records, fluid monitoring and some nutrition assessments. Night care was more focused on completing tasks than on supporting people's individual needs.
The manager had made improvements, including clearer staff roles and better support for staff. However, the home's audits had not identified several of the problems found during the inspection. The report made a recommendation about making the audit system effective.
Kind relationships
Inspectors found that staff knew people well and responded to their individual needs. People were supported respectfully and visitors were made welcome.
“There was a kind and caring relationship between people living at the home and the staff who looked after them.” from the report
Choice and independence
People were offered choices about food, clothing and daily life. Staff supported people to do as much personal care as they could for themselves.
“People were supported to maximise their independence.” from the report
Access to health care
Staff recognised when people were unwell and arranged medical support. Senior staff accompanied people to appointments with information about their care.
“People told us they were supported to access health care services when needed.” from the report
Staff training
Staff received induction, ongoing training and supervision. The manager had identified a need for more dementia-care training and had developed a course.
“The registered manager had a training plan in place which clearly identified the training staff needed and how often staff needed to complete refresher training.” from the report
Improving staff culture
Staff said that roles were clearer, support had improved and they felt more confident raising concerns. The manager was seen as approachable.
“The registered manager had introduced more structure into the home and staff were clear on what the job roles were.” from the report
Skin-care planning
seriousOne care plan had no assessment of skin health. Two people at high risk did not have matching care plans to show how pressure ulcers would be prevented.
“This meant that staff reacted to skin problems instead of working to prevent them occurring in the first place.” from the report
Night-time care
needs fixingThere were enough staff during the day, but people and visitors reported longer waits at night. Inspectors found that care could focus on completing tasks rather than people's choices and routines.
“At night care became task focused instead of person centred to help staff manage the workload.” from the report
Medicines records
seriousMost medicines were managed safely, but there was inconsistent recording of why medicines prescribed for use when needed had been given. Inspectors were particularly concerned about one person's medicine being used in connection with wandering.
“There was inconsistent recording of why medicines prescribed as required had been administered.” from the report
Food and fluid monitoring
seriousFood and drink records were incomplete. One person had no fluid intake recorded for 24 hours, and one person's thickened fluids were not consistently prepared as recorded.
“We saw the recording of food and fluid intake was inconsistent and at times it was not clear to see if people had received enough to drink to stay healthy.” from the report
Audits missed problems
needs fixingThe home's audits did not identify the concerns inspectors found about skin care, medicines and fluid records. The report also says earlier concerns had not been used effectively to drive improvement.
“However, these audits had not identified the concerns around supporting people to maintain healthy skin, correct administration of as required medicines and the recording of fluids that we identified during our inspection.” from the report
Activities and involvement
minorSome people and relatives wanted more activities. Some relatives also said they had not been involved enough in care planning or told clearly about meetings and activities.
“However, other people and relatives felt that it would be nice to have more activities to help people pass the day.” from the report
- 01What has changed in the skin-care plans for people at risk of pressure ulcers, and how do you check that prevention plans are followed?
- 02How do you record why medicines prescribed as required are given, and how do you review whether they are still needed?
- 03How do staff monitor and record each person's fluid intake, including people who need thickened drinks?
- 04How many staff are on duty at night, and how do you make sure night care remains person-centred when staff are busy?
- 05What activities are now available, especially for people living with dementia, and how are relatives involved in care planning and meetings?
This was an unannounced inspection covering all five questions and the overall rating, based on observations, discussions and records checked during the visit. This explanation was written from the published report of 7 July 2017 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 Kimberley Care Village
4 rated inspections over 4 years: the service has improved, from Inadequate to Good.
- March 2019Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2016Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Good
- April 2015InadequateSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- September 2013
Registered with the Care Quality Commission on 11 September 2013.
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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9 live-in carers within about an hour of Lincolnshire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
8 can care for a couple. 10 years' experience on average.
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