CQC report explained · a nursing home
What the CQC found at Shaftesbury Kenway Court
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Risk assessments were personalised, medicines were generally administered carefully, but some medicine records had gaps in signatures.
- Effective?
- Good
- Staff had the skills and guidance to meet people's complex needs. Staff worked with outside professionals and supported people's health, food and drink needs.
- Caring?
- Good
- People were treated kindly, with dignity and respect. Staff used personalised communication to help people make decisions, although some private information was left unattended.
- Responsive?
- Good
- Care was tailored to people's needs and reviewed regularly. The home offered flexible routines, individual activities and support with end-of-life care.
- Well-led?
- Good
- The home had an open, person-centred culture and an established manager. Staffing changes had put pressure on management time, and some supervision and competency checks had not been done as frequently as expected.
What inspectors found, April 2019
Livability Kenway Court was rated Good; inspectors found kind, personalised care, with some pressure on staffing and record checks.
This was an unannounced planned inspection on 5 March 2019, with the report also listing 6 March 2019. Inspectors spoke with people, families and staff, observed care, reviewed three care records and checked service documents and quality audits.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People were supported to make choices, stay independent and communicate their wishes. Staff knew people well and worked with health professionals to meet complex needs.
Inspectors found some areas needing attention. People said staff could feel stretched. There were gaps in some medicine signatures, private information had been left unattended, and management checks had not always been carried out as often as expected. The home had plans to increase staffing and strengthen checks.
Personalised risk support
Risk assessments gave staff practical guidance while supporting people to remain independent and make choices about risk.
“Risk assessments were practical and personalised. The registered manager promoted people's rights to choose to take risks and remain independent.” from the report
Communication and choice
Staff used different communication methods and a consistent approach so people could express their wishes and make daily decisions.
“During the day we observed all staff used the same approach when communicating with people, including domestic and lifestyle organisers.” from the report
Flexible activities
Support was adapted to individual interests and routines. The home provided dedicated staff and a minibus for activities and trips out.
“The service had dedicated staff to promote people's interests and a minibus for trips out.” from the report
Skilled health support
Nursing staff knew people well and worked with outside professionals when health concerns arose, including when people needed end-of-life care.
“When there were concerns the nurses had promptly accessed external professionals as needed.” from the report
Staffing sometimes felt stretched
needs fixingPeople said staffing could be thin at times. The provider planned to recruit more care staff and an additional nurse.
“Feedback from people told us staffing was adequate, but they felt staffing was often stretched.” from the report
Medicine records
needs fixingInspectors found gaps in medicine signatures. The medicine had been given safely, but it had not always been recorded properly.
“When we looked at the medicine records with the deputy manager we found some recording errors, such as gaps in signatures.” from the report
Private information
needs fixingMonitoring sheets containing private information had been left unattended. The manager agreed to address this.
“During the inspection we were able to see private information about people such as monitoring sheets which had been left unattended.” from the report
Management checks
needs fixingStaffing changes had reduced how often supervision and competency checks were completed. The new deputy and planned extra nurse were intended to improve this.
“This had left a void and practices such as supervision and competency checks were not being done as frequently as she or the provider expected.” from the report
- 01Has the planned additional nurse and increase in care staffing been completed, and do staff still feel stretched?
- 02How are medicine signatures and daily medicine checks now reviewed to prevent recording gaps?
- 03What steps are taken to keep monitoring sheets and other personal information secure?
- 04How often are staff supervision and competency checks now completed?
- 05How are people and families involved in reviewing care plans and activities as needs change?
This was a planned inspection covering all five key questions; the report lists visits on 05 and 06 March 2019 and says all five ratings remained Good. This explanation was written from the published report of 4 April 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.
What inspectors found, September 2016
Shaftesbury Kenway Court was rated Good; inspectors found safe, kind and personalised care, but identified gaps in records, activities and planning.
The unannounced inspection took place on 20 and 22 July 2016. Inspectors spoke with people living at the home, relatives, staff and outside professionals. They observed care and checked care plans, risk assessments, medicines records, staff files and quality checks.
The home provided nursing and personal care for up to 24 people with disabilities and complex needs. There were 22 people living there during the inspection. Inspectors found that people felt safe, staff understood their needs, medicines were managed safely and people could access healthcare and support with food and drink.
People were treated with respect and involved in decisions about their care. Care was tailored to individuals, and people were supported with activities and relationships. However, not everyone had daily activity opportunities, end of life plans were not in place for everyone, and some monitoring and recording systems needed improvement.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. This means inspectors found the service met the relevant standards at the time of this inspection, although Good does not mean that every part of the service was without problems.
People felt safe
People consistently said they felt safe. Staff knew about risks and had practical plans to support people safely, including when people chose to take risks.
“People consistently told us they felt safe using the service” from the report
Skilled and informed staff
Staff received induction, training and supervision. They understood people's complex health, communication and care needs, including when specialist advice was needed.
“People were cared for by staff who had the knowledge and skills required to meet their needs.” from the report
Kind and respectful care
Inspectors saw patient and compassionate interactions. People were supported to make choices, maintain relationships and have privacy.
“We saw kind and patient interactions between people and care staff.” from the report
Personalised support
The home assessed people before they moved in and used their histories, preferences and needs to develop individual care plans. People were supported with activities that suited them.
“People received care that was individual to them and personalised to their needs.” from the report
No documented computer backup plan
needs fixingCare plans and risk assessments were stored on computer software, but there was no contingency plan in case the system failed. The provider was trialling a plan elsewhere.
“there was no contingency plan if the computerised system failed.” from the report
Staffing calculations were not recorded
needs fixingInspectors found enough staff at the time, but the home could not provide documentation showing how staffing levels had been calculated. Staffing levels were being reviewed.
“documentation could not be provided which calculated how staffing levels were determined.” from the report
Relatives' involvement was not always recorded
needs fixingRelatives were welcomed in care planning, but they were not spoken to regularly about care plans. The computer system did not allow staff to record when relatives had been involved in reviews.
“The system did not allow staff to document where relatives had been involved in care plan reviews.” from the report
End of life plans were incomplete
needs fixingNot everyone had an end of life care plan, although inspectors found that people were receiving good end of life care through their general care plans. The manager had identified this as an area to address.
“End of life care plans were not in place for all people” from the report
Activities were not available every day
minorPeople had access to varied activities, including community trips, arts and fitness. However, two people and relatives said suitable opportunities were not available every day.
“two people and relatives reported that these opportunities and activities weren't available to them every day.” from the report
Complaint records were unavailable
minorThe complaints process was in place, but inspectors could not review complaint records because the complaints book had been misplaced. The manager said unresolved complaints were reported to the provider.
“the complaints book had recently been misplaced so we were unable to review any complaints records.” from the report
- 01How do you make sure relatives are invited to care plan reviews and that their involvement is recorded?
- 02What backup arrangements are now in place if the computerised care planning system fails?
- 03How do you calculate and record the staffing levels needed for each person's support?
- 04Does every person now have an end of life care plan, and how are their wishes discussed?
- 05How do you make sure each person has activities suited to them every day?
This was an unannounced inspection of the overall service and covered all five CQC questions, with a rating given for each one. This explanation was written from the published report of 7 September 2016 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 Shaftesbury Kenway Court
2 rated inspections over 3 years: the service has held its Good rating throughout.
- April 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 17 November 2010.
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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