CQC report explained · a residential care home
What the CQC found at Kimberley Grace Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from avoidable harm. Inspectors found regularly reviewed risk assessments, safe medicines arrangements, suitable recruitment checks, enough staff and infection control measures.
- Effective?
- Good
- Staff had training, supervision and support. People's dietary, health and communication needs were assessed, and the home worked with GPs, nurses and other professionals.
- Caring?
- Good
- People and relatives spoke positively about staff. Inspectors observed kind and respectful interactions, with people involved in decisions about their care.
- Responsive?
- Good
- Care plans were person-centred and regularly updated. People were supported with communication, activities, relationships, complaints and end-of-life planning.
- Well-led?
- Good
- The manager had introduced new care planning and monitoring systems. Regular audits, feedback and action plans were used to drive improvements.
What inspectors found, December 2021
Rated Good; inspectors found safe, kind and personalised care, with improvements since the previous Requires Improvement rating.
The unannounced inspection took place on 23 November 2021. One inspector spoke with seven people, three relatives and five staff. They reviewed care records, medicines records, staff files and management records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People and relatives were positive about the care. Inspectors found suitable staffing, safe medicines systems, staff training, regular care plan reviews and good links with health professionals.
The home had improved from Requires Improvement at its previous inspection, published in February 2020. Problems with risk assessments, medicines, staff support, care plans and quality monitoring had been addressed. The home was no longer in breach of the regulations identified at that inspection.
Improved care planning
A new care planning system had been introduced. Inspectors found that care plans and risk assessments were detailed, relevant and regularly reviewed.
“Care plans were detailed and contained all the information staff needed to support people safely.” from the report
Kind and respectful staff
People and relatives were positive about the staff team. Inspectors saw staff speaking with people respectfully and responding to distress with reassurance.
“Staff were kind and caring towards people, immediately addressing people's distress to offer reassurance with positive outcomes observed.” from the report
Staff training and support
Staff had completed training in areas including medicines, infection control, moving and handling, sepsis and end-of-life care. They also received supervision and support.
“Staff were supported to obtain the knowledge and skills they needed to provide care.” from the report
Good involvement and choice
People and relatives were involved in care planning and reviews. Staff supported people to make day-to-day choices and stay in contact with friends and relatives.
“People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible” from the report
Active quality improvement
The manager and provider had acted on the previous inspection findings. Audits and an action plan were being used to monitor and improve the service.
“Regular audits were completed and entered onto a home action plan to continuously drive improvements.” from the report
Inspectors raised no specific concerns in this report.
- 01How often will my relative's care plan and risk assessments be reviewed, and how will you tell me about changes?
- 02How do you calculate staffing levels, and what happens if more staff are needed?
- 03What activities would suit my relative's interests, communication needs and preferred level of social contact?
- 04How will you support my relative's dietary, swallowing, dental or other health needs?
- 05How do you monitor medicines, infection control and other safety arrangements on an ongoing basis?
This was an unannounced planned inspection covering all five CQC questions, including infection prevention and control measures; the report says it was prompted by the previous rating. This explanation was written from the published report of 24 December 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, February 2021
Inspected but not rated; Kimberley Grace Care Home had safe infection-control arrangements during the COVID-19 pandemic.
The CQC carried out an unannounced, targeted inspection on 3 February 2021. It looked only at infection prevention and control because of the COVID-19 pandemic.
Inspectors were assured that the home used personal protective equipment safely, arranged testing, supported isolation and followed social-distancing and shielding rules. They also found that new admissions were assessed, tested and supported to isolate.
Visits had stopped because of lockdown, except for people receiving end-of-life care. The home had plans for visits to restart, including a separate visiting area. People kept in touch with relatives by video and telephone.
The service was inspected but not rated. The report says the home was signposted to resources to develop its infection-control approach.
Testing and isolation
The home was carrying out whole-home testing and testing new admissions. New residents were supported to isolate after admission.
“The registered manager was following the government's guidance on whole home testing for people and staff.” from the report
PPE and infection control
Staff had pandemic-related training and training in the correct use of PPE. Inspectors were assured that PPE was used effectively and safely.
“We were assured that the provider was using PPE effectively and safely.” from the report
Keeping people connected
People were supported to keep contact with relatives by video and telephone. Staff continued activities chosen by the people living there.
“People's well-being was supported by video and telephone calls to relatives and staff continued to engage in activities with people of their choice.” from the report
Plans for visits
Although visits had stopped during lockdown, end-of-life visits were being facilitated and arrangements were ready for visits to restart.
“If people were on end of life care visits were being facilitated.” from the report
Further development needed
minorThe report does not describe a specific unsafe practice, but says the home was directed to resources to develop its infection-control approach.
“We have also signposted the provider to resources to develop their approach.” from the report
- 01What changes have you made to your infection prevention and control approach since the inspection?
- 02How do you currently test new residents and staff, and what happens if someone tests positive?
- 03How are visits arranged now, including visits for people receiving end-of-life care?
- 04What training do staff currently receive on PPE and working during an infection outbreak?
- 05What resources did you use to develop the infection-control approach after the inspection?
This was an unannounced targeted inspection of infection prevention and control only; the service was inspected but not rated and the other areas were not assessed. This explanation was written from the published report of 24 February 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.
Every inspection of Kimberley Grace Care Home
3 rated inspections over 3 years: the service has improved, from Requires improvement to Good.
- December 2021Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2021Inspected but not ratedSafe: Inspected but not rated
- February 2020Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- December 2018Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- June 2017
Registered with the Care Quality Commission on 8 June 2017.
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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