CQC report explained · a nursing home
What the CQC found at Kingsthorpe Grange
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, July 2024
Rated Requires Improvement, with an Inadequate well-led rating; inspectors found kind staff and safe medicines, but ongoing risks, dignity concerns and weak oversight.
This was an unannounced follow-up inspection. Inspectors and experts by experience spoke with people, relatives and staff. They reviewed care plans, medicine records, daily records and management checks.
The home had enough staff, people felt safe and staff were kind and respectful during personal care. Medicines were stored and administered safely. Staff worked with health professionals, and infection control arrangements were effective.
However, risks were not always identified or managed. Some care records were not personalised or up to date. Inspectors found concerns about missing clothing, activities, consent and restrictive practices, and responses to changes in people's health.
The overall rating was Requires Improvement. Safe, Effective, Caring and Responsive were also Requires Improvement. Well-led was rated Inadequate because the home's systems had not fixed problems found at earlier inspections. The home had been rated Requires Improvement for five consecutive inspections.
Safe medicines
Medicines were administered by trained staff and were ordered, stored and disposed of safely. Electronic records supported stock checks and reduced the risk of errors.
“People's medicines were administered by trained and competent staff and medicines were ordered, stored and disposed of safely.” from the report
Enough staff
Inspectors found enough staff to meet people's needs. People were attended to promptly, and recruitment checks were completed.
“There was enough staff to meet people's needs and keep them safe.” from the report
Kind personal care
People and relatives said staff treated people with kindness. Inspectors saw staff protecting people's privacy and dignity during personal care.
“Staff respected people's privacy and dignity when supporting people with personal care.” from the report
Healthcare support
Staff worked with GPs, dieticians and other professionals. This led to positive outcomes for some people.
“Staff worked in partnership with other professionals which had resulted in positive outcomes for people.” from the report
Infection control
The home was clean and free from unpleasant smells. Staff followed infection prevention procedures and protective equipment was available.
“During the inspection the home was clean and odour free.” from the report
Risks not managed
seriousSome risks to people's health and wellbeing had not been fully assessed or reduced. This included risks of self-harm or harm from other people.
“Risks to people who were vulnerable from self harm or harm from other people had not been fully assessed and mitigated.” from the report
Weak oversight
seriousThe home's checks did not reliably identify or fix problems. Inspectors found repeated failures in care records, safety checks, capacity decisions and health monitoring.
“The provider had failed to operate effective systems to assess and monitor the quality and safety of the service to identify and address areas for improvement.” from the report
Clothing going missing
seriousRelatives reported that clothing and belongings often went missing. Inspectors found unlabelled clothing in the laundry and wardrobes, despite this being a previous concern.
“This meant there was a risk of people wearing other people's clothes and personal belongings going missing.” from the report
Consent and restrictions
seriousCapacity assessments and best-interest records were not always complete. Inspectors found restrictive practices without legal authority, which had negatively affected one person.
“We found evidence of restrictive practices taking place within the service without the legal authority to do so.” from the report
Care and health records
seriousSome care plans lacked personal detail. Staff did not always complete required health observations or take further action when someone showed signs of deterioration.
“Where a person had shown signs of deterioration, staff had not carried out further observations as required.” from the report
Limited activities
needs fixingPeople, relatives and staff said there was not enough stimulation or enough activities matched to people's interests. Inspectors also saw missed opportunities for interaction.
“My [relative] constantly tells me she is bored, we are here every day and there is never activities, not enough stimulation.” from the report
- 01How have you assessed and managed risks of self-harm or harm from other people since this inspection?
- 02What system now ensures care plans include personalised information and are updated when people's needs change?
- 03How are you making sure health observations are completed and acted on when someone shows signs of deterioration?
- 04What temporary or permanent system is now in place to label and return people's clothing and belongings?
- 05What activities are now available, and how are they matched to each person's interests and hobbies?
This was an unannounced follow-up inspection covering all five CQC questions after the previous inspection, and the report says all five ratings remained Requires Improvement except Well-led, which fell to Inadequate. This explanation was written from the published report of 4 July 2024 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, September 2023
Kingsthorpe Grange rated Requires Improvement; inspectors found kind staff but concerns about risks, medicines, dignity and management.
This was an unannounced inspection over three days. Inspectors spoke with people, relatives and staff, observed care, and checked care plans, medicines records and management records.
The overall rating was Requires Improvement. All five areas were rated Requires Improvement: Safe, Effective, Caring, Responsive and Well-led. This means care was not consistently safe, effective, caring, responsive or well managed.
Inspectors found important risks that had not always been assessed or managed. Some time-sensitive medicines were not given at the same time each day. Clothing and bedding were not always suitable, and care records did not always give staff enough personalised information.
The home had strengths too. People and relatives said staff were kind and that people felt safe. Staff were trained, medicines were stored safely, infection controls were in place, and people were supported with food, drink and healthcare.
Kind and respectful staff
People and relatives said staff treated them kindly. Inspectors saw staff respecting privacy and dignity during personal care.
“People and their relatives told us staff treated them with kindness.” from the report
Staffing and safeguarding
People and relatives said they felt safe and there were enough staff. Staff had safeguarding training and understood how to report concerns.
“There were enough staff to meet people's needs and keep them safe.” from the report
Food, drink and healthcare
The home monitored people's weight and fluid intake, used fortified food where needed, and involved other professionals such as dieticians and diabetic nurses.
“People were supported to eat and drink enough to maintain a balanced diet.” from the report
Infection prevention
Inspectors were assured that the home had suitable arrangements to prevent and manage infection outbreaks.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Unmanaged risks and medicines
seriousSome risks, including self-harm and diabetes risks, were not fully assessed. Time-sensitive medicines were not always given at the right time, and guidance for some medicines was incomplete.
“People who were on time sensitive medicines for conditions such as Parkinson's disease did not always receive them at the same time.” from the report
Dignity, clothing and bedding
seriousRelatives reported missing clothing and people wearing other people's clothes. Inspectors also found unsuitable bedding, which could leave people cold or uncomfortable.
“People were not always treated with dignity and respect. This is a continued breach of Regulation 10” from the report
Weak quality checks
seriousThe home's monitoring systems did not identify several safety problems, including incorrect air mattress settings, missed repositioning and delayed action after high blood pressure.
“The provider had failed to operate effective systems to assess and monitor the quality and safety of the service” from the report
Care plans lacked personal detail
needs fixingCare records did not always explain people's preferences, communication needs or the support they needed with tasks such as oral care.
“People's communication needs and methods were not always recorded in care plans” from the report
Limited stimulation and orientation
needs fixingRelatives reported too little activity. Inspectors also found limited signs, incorrect clocks and unclear bedroom identification for people with memory or cognitive impairments.
“There was limited signage to support people to orientate themselves around communal areas” from the report
- 01How are you now assessing and managing risks for people with diabetes, self-harm risks and pressure sores?
- 02How do you make sure Parkinson's and other time-sensitive medicines are given at the same time each day?
- 03What system now ensures that clothes are returned to the right person and that everyone has suitable bedding?
- 04How have you improved care plans so they record people's preferences, communication needs and oral care requirements?
- 05What activities and support are now available, and how do you help people use the garden and find their way around the home?
This was an unannounced full inspection that looked at the home, the care provided and all five CQC questions. This explanation was written from the published report of 20 September 2023 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 Kingsthorpe Grange
8 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- July 2024Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- September 2023Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- August 2022Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- January 2022Inadequatedown from Requires improvementSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- July 2021Requires improvementSafe: Requires improvementWell-led: Requires improvement
- December 2020Inspected but not ratedSafe: Inspected but not rated
- August 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2016Requires improvementSafe: Requires improvementEffective: GoodCaring: Requires improvementResponsive: GoodWell-led: Good
- June 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 24 January 2011.
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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