CQC report explained · a nursing home
What the CQC found at Kineton Manor Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, December 2021
Kineton Manor Nursing Home was rated Good overall, but inspectors found medicines management was not always safe.
This was a focused inspection on 12 May 2021. Inspectors looked only at Safe and Well-led, after concerns about medicines and whether staff felt able to raise concerns. They spoke with people, relatives and staff, and checked care records, medicines records, audits and safety checks.
The home was rated Requires Improvement for Safe. People received their medicines as prescribed, but inspectors found expired medicines, missing storage temperature checks, gaps in disposal records and incomplete medicines care plans. They also found some risks with window restrictors and new admissions during the pandemic. The provider took immediate action on several issues.
The home was rated Good for Well-led. Inspectors found quality checks, a restructured management team and staff who felt able to raise concerns. The overall rating changed from Outstanding at the previous inspection to Good. The ratings for the other areas were carried over from the previous comprehensive inspection because they were not inspected this time.
Staff availability
Inspectors found staffing levels met people's needs. Staff supported people without rushing and responded promptly to call bells.
“Staffing levels met people's needs. During our visit we saw staff supporting people in an unrushed manner” from the report
Safeguarding awareness
Staff had safeguarding training and said they knew how to report concerns about abuse or unsafe care.
“Staff were trained in safeguarding and confident in reporting safeguarding concerns.” from the report
Supportive culture
Staff said managers were approachable and that they could raise concerns. A staff committee had also been created to improve communication.
“All the staff we spoke with told us they were confident in raising any concerns and would not hesitate to do so knowing they would be listened to.” from the report
Communication with relatives
Relatives spoke positively about the care and communication from managers and staff.
“Relatives spoke positively about their experiences of the home and the care and compassion demonstrated by managers and the staff team.” from the report
Medicine expiry and storage checks
seriousInspectors found expired medicines and other expired healthcare items. Staff were not regularly checking medicine expiry dates or recording storage temperatures.
“We found expired medicines for three people stored in the medicine trolleys.” from the report
Medicine records and disposal
seriousSome high-risk medicines were not stored securely and disposal records were incomplete. One care plan did not explain how staff should manage a person's seizure risk.
“High risk medicines were not always stored securely to meet regulatory requirements.” from the report
Environmental risks
needs fixingA first-floor window did not have suitable restrictors, and broken ropes on two sash windows created a possible injury risk. The provider took immediate action.
“One bedroom window above the ground floor did not have appropriate window restrictors in place to protect people from falling.” from the report
New admission isolation
needs fixingThe home had measures to reduce infection risks, but the recommended isolation period for new admissions was not always followed.
“the government's recommended isolation timescale for new admissions was not always being followed.” from the report
Missed serious injury notification
minorThe provider did not notify CQC about one serious injury. Inspectors considered this an oversight but reminded the provider of its legal responsibility.
“we did identify one occasion when we had not been notified of a serious injury.” from the report
- 01What checks are now used to make sure medicines are stored at the correct temperature and are not past their expiry date?
- 02How are high-risk medicines stored and disposed of, and how are disposal records checked?
- 03How are medicines care plans checked to make sure they explain specific timings and what staff should do during a seizure?
- 04What has been done to ensure all new admissions follow the recommended isolation timescale?
- 05How will the home make sure serious injuries and other notifiable incidents are always reported to CQC?
This was a focused inspection of Safe and Well-led only; the other ratings were carried over from the previous comprehensive inspection. This explanation was written from the published report of 14 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, May 2019
Rated Outstanding; inspectors found exceptionally caring, responsive and well-led care, with safe and effective care rated Good.
Inspectors visited on 23 and 25 April 2019. The first day was unannounced. They spoke with nine people, eight relatives or friends, 16 staff and two healthcare professionals. They also observed care and checked eight people's care records, medicines records, training, recruitment and quality checks.
The home was rated Outstanding overall. Caring, Responsive and Well-led were rated Outstanding. Safe and Effective were rated Good, meaning legal requirements were met and people's outcomes were consistently good.
Inspectors found enough skilled staff, safe medicines management, clean surroundings and good support with food, health and consent. They described particularly personalised care, strong family and community links, thoughtful activities and very strong support for people and relatives at the end of life.
The previous inspection in 2016 also rated the home Outstanding overall. Caring and Well-led remained Outstanding, while Responsive improved from Good to Outstanding. The report says the home continued to improve.
Kind and respectful care
People, relatives and visitors described a friendly atmosphere. Staff took time to talk with people and supported dignity, choice and independence.
“People, relatives and visitors to the home universally spoke of a 'friendly' atmosphere where the whole staff team were caring and compassionate” from the report
Personalised activities
The home supported people's interests, relationships, faiths and community connections. It also introduced sensory activities for people living with dementia and planned further developments.
“The service offered people opportunities to meet their individual cultural, psychological, spiritual, emotional and social needs, whatever their abilities.” from the report
End of life support
People were encouraged to plan their end of life care, and staff supported relatives before and after a death. The home also responded to people's religious, cultural and personal wishes.
“The registered manager and staff continued to demonstrate an extremely strong commitment to supporting people and their relatives before and after death” from the report
Strong leadership
Inspectors found motivated leaders who valued staff, encouraged learning and used reviews and incident analysis to improve care.
“The management team were proactive in driving the service forward.” from the report
Staff development
Staff received induction, ongoing training, supervision and opportunities to gain additional qualifications, including nurse associate training.
“There was a strong commitment to providing staff with the opportunities to develop in their role and take extra qualifications.” from the report
Fire safety practice
minorInspectors identified some fire safety issues. The provider acted immediately and said staff would be reminded to maintain good fire safety practice.
“Where we identified some issues, the provider took immediate action to resolve them” from the report
Used-needle containers
minorContainers holding used needles were not stored securely when inspectors found them. The registered manager took immediate action to make them secure.
“When we found special containers which contained used needles were not stored securely, the registered manager took immediate action” from the report
- 01What staffing levels and staff qualifications are in place now for people's varying and complex needs?
- 02What checks are now used to make sure fire safety practices remain consistent?
- 03Are Namaste Care and the Magic Table still being used, and how are activities adapted for people living with dementia?
- 04How are residents and families involved in creating and reviewing advance care plans for end of life care?
- 05How can a resident or relative raise a concern, and how quickly would the home respond?
This was a planned comprehensive inspection covering all five key questions, with the first inspection day unannounced and both the premises and care inspected. This explanation was written from the published report of 29 May 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 Kineton Manor Nursing Home
3 rated inspections over 5 years: the service has slipped, from Outstanding to Good.
- December 2021Goodcurrent ratingdown from OutstandingSafe: Requires improvementEffective: GoodCaring: OutstandingResponsive: OutstandingWell-led: Good
- May 2019Outstandingstayed OutstandingSafe: GoodWell-led: Outstanding
- July 2016OutstandingSafe: GoodEffective: GoodCaring: OutstandingResponsive: GoodWell-led: Outstanding
- June 2014
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- August 2012
Registered with the Care Quality Commission on 8 August 2012.
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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