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Kestrel Grove Nursing Home Good


Inspection carried out on 25 July 2019

During a routine inspection

About the service

Kestrel Grove nursing Home is a residential care home providing personal and nursing care to 53 people aged 65 and over at the time of the inspection. The service can support up to 57 people.

People’s experience of using this service and what we found

Systems and processes were in place to keep people safe and risks associated with people's care needs had been assessed. There were sufficient staff to meet people's needs and recruitment processes and procedures were robust. Medicines were managed safely. The service was clean, and there were appropriate procedures to ensure any infection control risks were minimised.

Staff received training and supervision in order for them to perform their role. People's nutrition and health were supported and promoted. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Staff knew people well and care plans were, detailed and provided staff with clear guidance on how to meets people's needs. Staff respected people privacy and dignity and encouraged people to remain independent. People and relatives could express their views about the running of the home.

People received outstanding personalised care and support which met their needs, reflected their preferences and promoted their self-worth. People benefitted from an excellent variety of activities, events and trips out that were available to reduce social isolation, give meaning and purpose and enhance their wellbeing.

The service provided exceptional and compassionate end of life care and took into consideration the needs of relatives and friends. Relatives praised the care and support both they and their family members received at this sensitive and emotional time.

The service was well led. People, staff and relatives spoke extremely positively about the registered manager and the provider. There was a positive culture throughout the service which focused on providing care that was personalised. The registered manager used a variety of methods to assess and monitor the quality of the service. They were aware of their regulatory responsibilities associated with their role.

For more details, please see the full report which is on the CQC website at

The last rating for this service was good (report published 05 January 2017). The service remains good.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our inspection programme. If we receive any concerning information we may inspect sooner.

Inspection carried out on 20 October 2016

During a routine inspection

The inspection took place on 20 &31 October 2016 and was unannounced. At their last inspection on 6 October 2015, they were found to not be meeting the standards we inspected. However at this inspection the provider had made all the required improvements. This was in relation to the care and welfare of people who used the service, people’s safety, consent, engagement and the quality monitoring of the service.

Kestrel grove is registered to provide accommodation for up to 57 older people who require nursing and or personal care. At the time of the inspection 57 people were using the service.

The home had a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People felt safe living at Kestrel Grove. Staff understood how to keep people safe and risks to people's safety and well-being were identified and managed. The home was calm and people's needs were met in a timely manner by sufficient numbers of skilled and experienced staff. The provider operated robust recruitment processes which helped to ensure that staff employed to provide care and support for people were fit to do so. People's medicines were managed safely.

Staff received regular one to one supervision from a member of the management team which made them feel supported and valued. People received support they needed to eat and drink sufficient quantities and their health needs were well catered for with appropriate referrals made to external health professionals when needed.

People and their relatives complimented the staff team for being kind and caring. Staffs were knowledgeable about individuals' care and support needs and preferences and people had been involved in the planning of their care where they were able. Visitors to the home were encouraged at any time of the day.

The provider had arrangements to receive feedback from people who used the service, their relatives, external stakeholders and staff members about the services provided. People were confident to raise anything that concerned them with staff or management and were satisfied that they would be listened to.

There was an open and respectful culture in the home and relatives and staff were comfortable to speak with the registered manager if they had a concern. The provider had arrangements to regularly monitor health and safety and the quality of the care and support provided for people who used the service.

Inspection carried out on 6 October 2015

During a routine inspection

This inspection was carried out on 6 October 2015 and was unannounced.

Kestrel Grove Nursing Home provides accommodation and personal care for up to 57 older people, some of who live with dementia. There were 55 people living at the service on the day of our inspection. There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

When we last inspected the service on 26 November 2013 we found them not to be meeting the required standards in relation to their management of medicines. At this inspection we found that they had addressed the shortfalls identified previously, however, there were areas that required improvement. These areas related to the security of the home, pressure care equipment, moving and handling, infection control and the recording and storage of medicines. In addition, there were areas in relation to relationships between people and staff.

CQC is required to monitor the operation of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. DoLS are put in place to protect people where they do not have capacity to make decisions and where it is considered necessary to restrict their freedom in some way, usually to protect themselves or others. At the time of the inspection applications had been made to the local authority and authorised in relation to people who lived at the service. Staff were not clear of their role in relation to MCA and DoLS and required further support to improve their understanding. This included assessing people’s capacity to ensure they were decision specific to promote people’s autonomy.

People received care that met their needs and care plans included up to date information. People were positive about the staff and how they were supported, however, at times support was task orientated and lost the personal, holistic approach. Activities were limited and required some improvement to reflect people’s individual strengths, hobbies and interests.

There was a variety of food and people enjoyed their meals. There was appropriate support for people to eat and drink sufficient amounts. People had access to health and social care professionals.

People knew how to make a complaint and these were acted on appropriately. Feedback was sought through meetings and surveys. There were systems in place to enable the manager to identify and address any issues. People, their relatives and staff were positive about the management team.

Inspection carried out on 26 November 2013

During a routine inspection

We observed that staff were attentive to people's needs and treated them with respect and dignity calling them by their name. We saw that staff sought people`s agreement before providing any support and assistance. We saw that the provider gave due consideration to people's capacity to consent, and that they had taken the relevant action to ensure that they complied with the Mental Capacity Act 2005.

We saw that staff were knowledgeable about people's needs and promoted their independence. We found that they had a good understanding and awareness of people's care needs and preferences. We saw that care plans and risk assessments were regularly reviewed and updated.

People told us that there were sufficient numbers of staff on duty to meet the needs of the people who lived in the service. All of the people we spoke with were extremely complimentary about the staff, activities and the varied choice of meals. One person who used the service told us, "If you had to live in a home then this is where it should be." Another person told us "Staff escorts me to my appointments and the staff knows my little ways." Another person told us that "I have been able to negotiate core team of five staff who are very aware of my complex needs, this means that I have consistency in how my care is provided.

We found that people were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to manage medicines.

Inspection carried out on 6 March 2013

During a routine inspection

People we spoke to were satisfied with the care they received and found the staff to be friendly and helpful. One person told us, "The staff are quite good, excellent really; they�re always friendly and helpful� and that �the food is okay, on the whole it�s quite good, there are lots of activities to do here and we have a happy hour with drinks�. Another person told us, �The staff are excellent, the carers really do �care�, they respect your dignity, the food is good and you get a choice, but it�s not always hot though. The staff go to a lot of bother�.

People were satisfied that there was plenty of activities if they wanted to get involved.

People told us how their privacy and dignity was respected and that staff always closed the doors when they're helping with personal care. Although some people told us that not all staff knock and wait before entering their room.

We observed the home to be visibly clean on the day of our visit; all the people appeared to have had their personal care needs met.

Staff told us how they enjoyed working at the home and felt supported by management.

Overall the service was meeting standards although we did make some minor comments to the provider with regards to care plans, audits and the training record for one person.

Inspection carried out on 27 February 2012

During a routine inspection

During our visit on 27 February 2012, people we spoke with were all complimentary about the care and service provided. A person remarked, �The service is very good and the staff are extremely good.�

Another person we spoke with said, ��Staff are wonderful and kind� This was echoed by another person who said, �The care is good. The staff are very good.�

Another person said, �At mealtimes, the staff help me; they cut up my food for me. I can ring for help from my bedroom. There are choices, including take-away food. We had Chinese take-away the other day. They ordered roast duck which I like.�

When asked about choices and activities, a person commented, �There are different activities. I don�t go to all of them. I do like flower arranging which I attend.� Another person said, �Very good service. We have a choice of menu. The food is good and there is plenty to eat; more than enough.�

A person we spoke with said, �I am invited to the activities such as bingo which I join in sometimes; but mostly I prefer to do crosswords.�

Another person said, �I have attended residents meetings; we can say what we want and we do get what we want.�

A relative we spoke with commented, �Very good service. Staff are marvellous.� This was echoed by another visitor who said, �Very good service; very good staff; can�t fault them.�