CQC report explained · a nursing home
What the CQC found at Kimberly West & East Care Centres
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found safe recruitment, safeguarding training, risk assessments and medicines management. There was conflicting feedback about staffing and cleaning, and one housekeeping vacancy affected more thorough cleaning.
- Effective?
- Good
- People had access to food, drinks and health professionals, and staff received training and supervision. Fluid charts were not consistently completed, and some consent records did not clearly show who had legal authority to consent.
- Caring?
- Good
- Inspectors saw kind and friendly interactions, and people and relatives were mostly positive about staff. One disrespectful interaction was observed, and some people said they had sometimes waited for help to use the toilet.
- Responsive?
- Good
- The home offered activities, supported communication needs and responded to complaints. Care plans contained some useful personal information, but other guidance and daily records were not detailed or person-centred enough.
- Well-led?
- Requires improvement
- The management team had audits, meetings and a development plan, but records were not fully integrated or consistently reliable. Call bell response times were not routinely checked, and some people and relatives did not feel able to give feedback freely.
What inspectors found, June 2020
Rated Good overall; inspectors found kind, effective care, but the home's leadership and records required improvement.
Inspectors visited on three days in November and December 2019. The first day was unannounced. They spoke with people, relatives, staff and health professionals, and checked care, medicines, staffing and management records.
The home was rated Good for Safe, Effective, Caring and Responsive. Inspectors found safe medicines management, suitable training, kind interactions, activities and support from health professionals. They also found good support for rehabilitation and end of life care.
Well-led was rated Requires Improvement. Care plans, fluid charts and some risk records were not consistently complete. Call bell response times were not routinely checked. Some people and relatives also felt unable to give feedback freely because of the cameras.
The overall rating remained Good, the same as at the previous inspection. However, the well-led rating fell from Good to Requires Improvement.
Kind staff
People and relatives were complimentary about staff. Inspectors observed positive interactions, including sensitive support with moving and eating.
“There were some positive, kind and friendly interactions between people and staff.” from the report
Health and rehabilitation support
People were supported by several health professionals. Inspectors found that joint working helped many people receiving short-term care to return home successfully.
“People were supported by a range of health care professionals, to keep well and maximise their independence.” from the report
Medicines
Medicines were stored securely and given by trained staff. An electronic system helped check stock and when medicines were due.
“People's medicines were safely managed. An electronic medicine administration system was used which promoted greater accuracy.” from the report
Activities
People could take part in a range of social activities, including music, reminiscence groups, outings and activities with children from a local nursery.
“People were complimentary about the social activities offered.” from the report
End of life care
Staff had training in end of life care and supported people's wishes and relatives. A room was available for relatives who wanted to stay.
“The staff have done some incredible end of life work.” from the report
Incomplete care records
needs fixingSome care plans, daily records, fluid charts and risk records were incomplete or inconsistent. The home said this was linked to changing from paper to electronic records, but the new system was not yet fully embedded.
“Some records did not show people had enough to drink and information within people's care plans was variable.” from the report
Call bell monitoring
needs fixingCall bell response times were not routinely checked. This meant the home could not reliably identify whether people had waited too long for help.
“Call bell response times were not routinely checked.” from the report
Privacy of feedback
minorSome people and relatives did not feel able to speak openly to inspectors because they were concerned that CCTV cameras could identify them.
“Some people and their relatives did not feel they could freely give us feedback about the service.” from the report
Dignity and waiting for help
needs fixingInspectors observed one disrespectful interaction. Some people also reported waiting for help to use the toilet, which could affect their dignity.
“Sometimes I've had to wait [to go to the toilet] and you know it'll be an accident in the bed.” from the report
- 01What has been completed to make the electronic care records fully accurate and consistent?
- 02How do you now check that people receive enough to drink, and how are fluid records reviewed?
- 03How are call bell response times monitored, and what happens if someone waits too long?
- 04How do you make sure staff consistently protect people's dignity and speak respectfully?
- 05How can people and relatives give confidential feedback about care and the CCTV system?
This was an unannounced inspection covering all five CQC questions; it was prompted by concerns about staffing and people's care, and the previous overall rating was Good. This explanation was written from the published report of 6 June 2020 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 2019
Rated Good; inspectors found safe, kind and well-organised care, but some monitoring records were incomplete.
Inspectors visited without notice on 11 and 13 December 2018. They spoke with people, relatives, staff and healthcare professionals. They reviewed care plans, recruitment files, medicines records and management records.
The home received Good ratings in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines systems, clean premises, suitable training and care that respected people's dignity and choices.
The main shortfall was record keeping. Some records did not show clearly whether people had been repositioned or had received enough fluids. The home was moving to electronic care records, and inspectors made one recommendation to improve monitoring records.
Kind and respectful staff
People and relatives said staff were kind, caring and respectful. Inspectors saw staff protect privacy and support people at a pace that suited them.
“People and their relatives told us all the staff at Kimberly West & East Care Centres were kind and caring.” from the report
Safe staffing and recruitment
The home completed required checks before employing staff and had enough staff to meet people's needs. Staff understood safeguarding and how to report concerns.
“There were sufficient staff available and we observed people had support at the time they needed it.” from the report
Good health support
People were referred to healthcare professionals when needed. Those receiving intermediate care had support from a team including therapists and a nurse practitioner.
“People had their healthcare needs met by healthcare professionals.” from the report
Activities and community links
People could join varied activities, spend time in the community and receive visiting services such as hairdressing and chiropody.
“The service provided daily newspapers for anyone to pick up and read.” from the report
Open management
People, relatives and staff were asked for feedback in several ways. The management team used this information to make changes, including improving communication with relatives.
“Systems were in place to monitor quality and safety. Where needed, action was taken to make improvements.” from the report
Incomplete monitoring records
needs fixingSome records did not clearly show whether people had been repositioned as required or had received enough fluids. Inspectors recommended improving the way monitoring is recorded so care can be checked more easily.
“We could not be sure they had been repositioned at the required times.” from the report
Medicines storage temperatures
needs fixingTemperature records were missing for one medicines room on the first inspection day. Records for another medicines room showed temperatures were often above 25 degrees, although the provider took action during the inspection.
“Records for the temperatures of the medicines rooms in Kimberly West demonstrated the temperature was often over 25 degrees.” from the report
- 01How do you now make sure repositioning and fluid intake are recorded fully and in one place?
- 02How do you check medicines room temperatures every day, and what action is taken if they are too high?
- 03How will the move to electronic care records improve checks on people's daily care?
- 04How do you make sure staffing levels change when people's needs change?
- 05How are relatives kept informed about a person's progress and care?
This was an unannounced first inspection that looked at both the accommodation and care provided and rated all five key questions. This explanation was written from the published report of 26 January 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 Kimberly West & East Care Centres
2 rated inspections over a year: the service has held its Good rating throughout.
- June 2020Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Kimberly West & East Care Centres →
- January 2019GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Kimberly West & East Care Centres →
- November 2017
Registered with the Care Quality Commission on 23 November 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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