CQC report explained · a nursing home
What the CQC found at Kings Manor Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm, and staff understood risks and safeguarding procedures. However, inspectors found inconsistent records for pain relief patches and some expired sterile products.
- Effective?
- Good
- People's needs and choices were assessed, and staff had a wide range of training. Specialist training in complex dementia care had not yet been completed, but it was sourced and booked during the inspection.
- Caring?
- Good
- People were treated with kindness, dignity and respect. Inspectors saw staff listening to people and supporting their choices and independence.
- Responsive?
- Good
- Care plans were detailed and personalised, and activities were based on people's interests where possible. Some relatives were unsure whether care plans reflected current needs, and communication was not always consistent.
- Well-led?
- Good
- The management team used audits and an action plan to monitor quality and make improvements. Some relatives wanted more regular contact, and the home planned extra family liaison meetings and surveys.
What inspectors found, October 2021
Rated Good; inspectors found kind, personalised care, with some delays and record-keeping issues to watch.
This was the first rating inspection since the home registered in 2019. Inspectors visited unannounced on three dates in September 2021. They spoke with people, relatives and staff, observed care, and checked care plans, medicines, training, recruitment and quality records.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. People generally said they felt safe and well cared for. Inspectors saw staff being patient, kind and calm, including during a medical emergency.
There were some problems. Help could be delayed at busy times. Relatives raised concerns about personal care and communication. Inspectors also found medicines records and sterile product checks that needed improvement. The home acted during or after the inspection, including arranging extra dementia training, removing expired products and changing some audit checks.
Kind and respectful care
People and relatives generally said they felt safe and well cared for. Inspectors saw staff acting with patience, warmth and compassion.
“Staff understood people's needs and responded to them patiently and were warm and friendly at all times.” from the report
Personalised support
Care plans described people's needs and preferences. Staff adjusted support to people's choices, including their preferred routines and communication methods.
“Care plans were detailed and personalised to show how care and support should be delivered in line with individual's needs and preferences.” from the report
Good emergency response
Staff responded promptly when a person became very unwell. They involved nursing staff, called paramedics and supported the person throughout.
“Staff took immediate action including involving one of the nurses, calling paramedics and supporting the person before and once this had arrived.” from the report
Quality monitoring
The home used audits, accident reviews and an action plan to identify and address improvements.
“Audits were used to analyse accidents and incidents to see if there were any patterns and trends.” from the report
Delays at busy times
needs fixingStaffing was judged sufficient, but pandemic-related staffing pressures sometimes meant people waited longer for help at peak times. Inspectors said this had not compromised safety.
“care and support may be delayed slightly for some people at peak busy times.” from the report
Personal care checks
needs fixingThree relatives said personal care was sometimes below the standard they expected, including concerns about fingernails. Managers said they had not previously been made aware and planned more direct family feedback.
“there were occasions when their relatives personal care was not as good as they had expected such as dirty or long fingernails.” from the report
Medicines records
needs fixingRecords did not always show where pain relief patches were applied, whether they remained in place or whether old patches had been removed. Some clinic room records lacked actions, and several sterile products were past their expiry date.
“The recording of the location of application of the patch was inconsistent.” from the report
Communication with relatives
minorSome relatives said contact from the home was not regular or consistent enough. The home agreed to consider improvements, including evening family meetings and surveys.
“Some relatives said that communication was not always consistent and three said they would like more regular contact from the service about their loved one.” from the report
- 01How do you make sure people are helped promptly during busy times or when staffing levels fall below your preferred numbers?
- 02How do you check that personal care, including nail care, is completed to the expected standard?
- 03What new checks now confirm that pain relief patches remain in place and that previous patches have been removed?
- 04How do you make sure sterile products are checked before their expiry date?
- 05How will relatives receive regular updates, and how can they join the planned family meetings or surveys?
This was the first full rating inspection and covered all five key questions, including both the premises and the care provided. This explanation was written from the published report of 6 October 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, December 2020
Inspected but not rated; inspectors found kind care and improving management, but staffing levels and records needed attention.
This was the home's first inspection. It was an unannounced targeted inspection on 11 November 2020, looking mainly at staffing, food and fluid records, care records, management and infection control.
People said they felt safe and that staff were kind and patient. However, staffing was sometimes too low. This meant people waited longer for help, and staff had less time to provide emotional support.
Risk assessments were reviewed, but food and fluid records were not always completed properly. Care plans were safe enough for basic care, but did not always record people's personal preferences. The provider had already started an action plan, recruited more staff and brought in experienced support staff.
The home was inspected but not rated. This means the inspection did not assess all areas needed to give ratings. The report says the full key questions would be assessed at a later comprehensive inspection.
People felt safe
People told inspectors they were happy and felt safe. Staff said they put residents first, even when staffing was difficult.
“People told us they were happy and felt safe living at Kings Manor.” from the report
Infection control
Inspectors were assured that the home had measures for preventing and managing infection, including use of protective equipment and testing.
“We were assured that the provider was using PPE effectively and safely.” from the report
Improvement support
The provider had already identified problems and put an action plan and experienced support team in place.
“The provider had identified areas for improvement and put an action plan and a team of senior support staff in place to drive improvement.” from the report
Staffing levels
needs fixingThere were occasions when fewer staff than planned were on duty. This caused delays with personal care, meals and call bells, and limited time for emotional support.
“There were not always enough staff to meet peoples needs.” from the report
Food and fluid records
needs fixingFood and drink charts were not completed consistently. This made it harder for staff to know how much some people had eaten and drunk.
“completion of food and fluid charts was inconsistent, meaning staff could not be sure how much people had to eat and drink.” from the report
Personalised care plans
needs fixingCare plans gave enough basic information for safe care, but did not always explain how people wanted support or record their preferences.
“People's care plans did not consistently give staff enough information to be able to meet people's needs and preferences.” from the report
Management changes
minorThe registered manager and three clinical staff had recently left. An interim manager and support team were in place while recruitment continued.
“The previous registered manager and three clinical staff had recently left their roles.” from the report
- 01How many staff are planned for each shift, and how often are shifts below that level now?
- 02How quickly are call bells answered, and how do you check for delays with personal care and meals?
- 03How do you make sure food and fluid charts are completed accurately and reviewed when someone loses weight?
- 04How have care plans been improved so they record each person's preferences and the way they want support?
- 05Who is managing the home now, and what progress has been made in appointing a registered manager?
This was a targeted inspection of specific concerns about staffing, records, management and infection control; it did not assess the whole of the key questions and therefore gave no ratings. This explanation was written from the published report of 24 December 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.
Every inspection of Kings Manor Care Home
Each visit the CQC has published, newest first, back to the day the home was registered.
- October 2021Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2020Inspected but not ratedSafe: Inspected but not ratedResponsive: Inspected but not ratedWell-led: Inspected but not rated
- June 2019
Registered with the Care Quality Commission on 11 June 2019.
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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