We carried out a review of the data available to us about Kibworth Court on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Kibworth Court, you can give feedback on this service.
Kibworth Court is a residential care home providing personal care and accommodation for up to 45 older people in one adapted building. At the time of our inspection there were 35 people using the service, many of whom were living with dementia.
People’s experience of using this service and what we found
There were systems and processes in place to safeguard people from potential harm. Staff completed training about safeguarding and knew how to identify and report abuse. Risks to people were assessed and measures were put in place to reduce them.
People were supported by sufficient numbers of staff to meet their needs and keep them safe. People received their medicines safely and as prescribed. Staff understood their responsibilities and followed safe practices to protect people from the risk of infections. There were systems in place to ensure lessons were learned when things went wrong, so that improvements could be made to the service and the quality of care provided.
Staff underwent training to ensure they had the skills and knowledge to meet people's needs and provide personalised care. People were supported to maintain good health and well-being. They were encouraged to maintain a balanced diet and their nutritional needs were met.
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.
The service had governance systems in place to ensure the service and quality of care provided were continuously assessed and monitored. A range of audits were in place to monitor the quality and safety of service provision. People, relatives and staff were consulted about the service and feedback used to drive improvements and develop the service.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and follow up
The last rating for the service was Requires Improvement (published on 11 September 2021). We found breaches of Regulations 12 and 17 and issued a Warning Notice. We undertook a focused inspection on 12 January 2022 (published 10 February 2022). Although we did not change the rating of requires improvement, we found the provider had met the requirements of the Warning Notice and was no longer in breach of regulations.
Why we inspected
This inspection was prompted by a review of the information we held about this service.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.
Kibworth Court is a residential care home providing personal care for up to 45 older people in one adapted building. At the time of our inspection, there were 35 people using the service, many of whom were living with dementia.
People's experience of using this service and what we found
Staff followed infection prevention and control procedures to protect people from the risk of infections and COVID-19 as far as possible. Staff wore the recommended personal protective equipment when working in the service and providing care and support. The provider had made improvements to the maintenance and cleanliness of the premises. Further improvements were needed to ensure standards were embedded into staff working practices, and ensure consistency in cleaning and housekeeping.
People and staff were supported to participate in regular testing for COVID-19. People were able to have visits from their relatives in line with current government guidance. The provider understood the requirement to make sure all non-exempt care staff and other professionals visiting the service had been vaccinated with a complete course of an authorised vaccine for COVID-19.
The provider and registered manager had further developed audits and checks to ensure shortfalls were identified and timely action taken. Housekeeping and cleaning audits required further development to identify areas where cleaning standards were not consistent or fully embedded into staff working practices.
Rating at last inspection and update
The last rating for this service was requires improvement (published 11 September 2021) and there were breaches of regulations.
The provider completed an action plan after the last inspection to show what they would do and by when to improve.
At this inspection we found improvements had been made in Safe and Well-Led and the provider was no longer in breach of regulation 12 or regulation 17.
You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Kibworth Court on our website at www.cqc.org.uk.
Why we inspected
We undertook this targeted inspection to review whether the Warning Notice we previously served in relation to Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met. The warning notice also detailed our concerns about infection prevention and control measures at the service and the breach of Regulation 12.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
CQC have introduced targeted inspections to follow up on Warning Notices or to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our reinspection programme. If we receive any concerning information we may inspect sooner.
Kibworth Court is a residential care home providing accommodation and personal care to 29 people aged 65 and over at the time of the inspection. The service can support up to 45 people accommodated over two floors.
People’s experience of using this service and what we found
The service did not have robust systems and procedures in place to ensure the quality and safety of the service was maintained.
The safety, equipment and cleanliness in several people’s bedrooms placed them at risk of infection including COVID-19. There was not enough staff to ensure the required cleaning and maintenance of bedrooms was undertaken frequently enough.
Environmental safety concerns were found in communal areas. A cupboard and hair salon were not secured. These rooms presented risks to people’s health because of the products contained within them and their poor state of repair.
The provider was responsive to our concerns and took immediate action to address the concerns we identified.
People and relatives had not been offered opportunity to feedback on the quality of the service. Relatives were not always involved in the development and review of their relatives’ care needs.
People, their relatives and staff were complimentary about the registered manager who listened and communicated well with them.
Whilst several relatives raised concerns over staffing levels, we found there were enough experienced and qualified staff to safely meet people’s personal care needs, which were assessed and monitored well. Where people’s needs changed, prompt action was taken to ensure their health and well-being were maintained.
People were supported by safely recruited staff who were kind, considerate and knew them well. Staff understood and recognised signs of abuse, and how and who to report any concern to.
People received their medicines when they needed them, and accidents and incidents were reported and acted on.
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.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (published 3 January 2018)
Why we inspected
The inspection was prompted in part due to concerns we received in relation to safe care. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.
We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection. The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
Whilst we found no evidence to support the concerns, we received prior to the inspection we did find concerns in other areas of the service during our inspection. We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report.
You can see what action we have asked the provider to take at the end of this full report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Kibworth Court on our website at www.cqc.org.uk.
Enforcement
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.
We have identified breaches of regulation in relation to infection control, environmental safety and the governance arrangements at this inspection. We issued the provider with a warning notice relating to governance arrangements in place. Please see action we have told the provider to take at the end of the report.
Follow up
We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
We found the following examples of good practice.
¿ Sufficient stocks of Personal Protective Equipment (PPE) were in place including masks, gloves, aprons, hand sanitiser and visors. Staff were wearing this appropriately.
¿ Infection control polices reflected the current national guidance and had been reviewed regularly. Cleaning schedules had been increased to ensure touch surfaces were cleaned regularly and additional cleaning to maintain good hygiene standards.
¿ People living in the service and staff were being tested regularly. This was to ensure if any staff or people had contracted COVID-19 and were asymptomatic, this was identified and acted upon in a timely way.
¿ There was a clear process for visitors, which included a risk assessment, temperature check and the wearing of PPE. The environment for visitors was COVID-19 secure and followed national guidance for visitors to care homes.
¿ Staff had received training in the use of personal protective equipment (PPE), and we saw this was accessible throughout the home and staff used it in accordance with the most up to date guidance.
¿ There was a clear procedure in place, in line with national guidance to ensure people were admitted to the service safely.
Further information is in the detailed findings below.
At the last inspection on 10 December 2016 the service was rated Requires Improvement. We rated the safe, responsive and well-led domains as requiring improvements. We asked the provider to make the necessary improvements. At this inspection we found that the required improvements had been made and the service was rated Good overall.
There was a registered manager in place. It is a requirement that the service has 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. Staff understood their responsibilities to keep people safe from avoidable harm. There were a suitable number of staff deployed and the provider had followed safe recruitment practices. Where risks were identified for people while they were receiving support these had been assessed and control measures put in place. People received their medicines in line with their prescription.
Staff had access to the support, supervision and training that they required to work effectively in their roles. Where agency staff were used, induction was provided to make sure that they were able to meet people's needs.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible.
People had enough to eat and drink to maintain good health and nutrition. People were supported to access health professionals when required.
People were treated with kindness and compassion. Dignity and respect for people was promoted.
People had care plans in place that focused on them as individuals. This enabled staff to provide consistent care in line with people's personal preferences.
The service had a positive ethos and an open culture. The providers and registered manager provided positive leadership to all staff.
The provider had sought feedback from people and their relatives about the service they received. They had taken action based on this feedback.
The provider's complaints procedure had been followed when a concern had been raised and people felt able to make a complaint if they needed to.
The provider had quality assurance systems to review the quality of the service to help drive improvement.
Kibworth Court provides care and support for up to 45 older people. At the time of our inspection 36 people were using the service and many were living with dementia.
At the last inspection on 8 and 9 June 2015 we asked the provider to take action to make improvements. We asked them to improve their practice in relation to making sure that people had the equipment in place to meet their safety requirements. We had concerns that people’s care plans did not have all of the information required to guide staff on how to meet people’s individual needs. We found that people’s care records were not always safely stored. We also had concerns that the provider had failed to act in accordance with the Mental Capacity Act 2005 (MCA) and that staff did not understand the requirements of this law. Further, we required the provider to make improvements to their quality assurance systems which we found had not adequately assessed, monitored and mitigated the risks to people that used the service. Following that inspection the provider sent us an action plan setting out what they were going to do. At this inspection we found that the provider had made most of the required improvements in these areas.
There was a registered manager in place. It is a requirement that the service has 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.
Risks to people’s health and well-being were assessed including where people were at risk of falling. Some assessments did not detail the equipment people required and the registered manager told us they would make improvements. We found that people had the equipment they required to remain safe. There were risks within the home that people could have been exposed to. For example, laundry obstructed a fire door and partially covered a fire extinguisher. The provider told us they would take action to make improvements. Where some areas of the home required upgrading, the provider had a refurbishment plan in place.
People’s care plans did not always contain information and guidance for staff to follow. For example, where people required assistance to move using equipment, detailed information and guidance was not always recorded. However, staff knew about people’s preferences and support needs and people received care that was based on these. People or their relatives contributed to the planning and review of their care requirements.
People received their medicines when they required them from staff who understood their responsibilities. Where people required as and when required medicines such as pain relief, the provider did not have written guidance for staff on the circumstances of when these should be offered to people. They told us they would review their policy and practice in line with national medicines guidance.
The provider had a range of checks on the quality of the service to make sure it was of a good standard. For example, checks on people’s medicines took place. However, the quality checks did not always identify areas for improvement that we found. This included incomplete information within people’s care plans and some unclean areas of the home. The provider had sought feedback from people, their relatives and staff about the quality of the service. They took action where feedback was received.
Staff had mixed views about how well the service was managed. They told us that the registered manager and proprietors were not always approachable. People and their relatives told us that they felt the home was managed well. We found that the registered manager was available and gave time to people and staff during our visit. The registered manager was aware of their responsibilities and had notified us of significant events at the service.
People had mixed views on the opportunities for them to take part in hobbies and interests that they enjoyed. The provider told us that they were looking to replace an activities worker that had recently left their employment.
Staff were knowledgeable about their responsibilities to report their concerns about the unsafe or inappropriate practice of their colleagues should they have needed to. The provider told us that they would review their whistleblowing policy to include the details of other organisations staff could raise their concerns with should they need to. Staff kept people’s records stored safely and spoke about people’s care requirements in private.
Staff understood their responsibilities to protect people from abuse and avoidable harm and to remain safe. Where accidents or incidents occurred, the provider took action to look at ways of preventing a reoccurrence. The provider had emergency plans in place to meet people’s safety needs in the event of a significant incident such as a fire. We saw that staffing numbers were suitable to help people to remain safe and to offer them care and the provider had increased staffing due to an increase in the amount of falls people had experienced. Prospective staff were checked for their suitability before working for the provider.
Staff had the necessary skills and knowledge and received support and guidance. Staff received training in areas such as dementia care and fire safety. Staff received an induction when they started working for the provider so that they were aware of their responsibilities. Staff also received guidance and feedback from the registered manager to make sure they were delivering care that met people’s care requirements.
People were supported in line with the Mental Capacity Act 2005. Staff asked people for their consent when offering their support. Where there were concerns about people’s ability to make decisions, the registered manager had assessed people’s mental capacity. The registered manager had made applications to the appropriate body where they had sought to deprive a person of their liberties.
People and their relatives were satisfied with the food and drink available to them. People enjoyed their food and there were different options available to them. Where there were concerns about people’s eating and drinking, the provider was monitoring this to make sure people ate and drank well. People were supported to maintain their health and well-being. This included having access to healthcare services such as to their GP and community nursing.
People described staff as kind. People’s privacy and dignity was respected by staff. We saw that staff listened to people about things that mattered to them. People’s families could visit without undue restriction. This meant they maintained relationships that were important to them.
People were supported to retain skills to maintain their independence where this was important to them. For example, one person was encouraged to walk to retain their mobility. Some people were involved in decisions about how their care was provided. Other people received the support from their families or representatives who were involved in making decisions about their care to make sure it was provided in ways that were important to people.
People and their relatives knew how to make a complaint. The provider had a complaints policy in place which was displayed so that people and visitors knew the process. Where a complaint was received, the provider took action.
The inspection took place on 8 and 9 June 2015 and was unannounced.
At our last inspection on 9 June 2014 the service was meeting the regulations.
Kibworth Court is a 40 bed care home located in the village of Kibworth Beauchamp in Leicestershire, and is for men and women with age related needs including dementia. Accommodation is arranged over two floors. Access to the upper floor was by stairs or lift.
There should be a registered manager at the service. A registered manager is a person who has registered with the Care Quality Commission 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. At the time of our inspection the manager at the service had been in post for three months and was just beginning the formal registration process.
Since the new manager had been in post staff members told us that positive changes had been made. These included the introduction of staff supervision. We found that although there appeared to be a lot of work in progress and ideas in development there were a number of concerns that needed addressing urgently.
People told us they were happy at the service and that staff were nice. Staff spoke kindly to people when they supported them with tasks. However, people received little interaction from staff and there were no regular activities that took place.
Staff told us how they were in the process of reassessing people’s needs and completing care plans to ensure that their care needs were met. We found that at the time of our inspection that some people were not receiving care and treatment that met their needs.
People told us that they enjoyed the food at the service, although relatives told us it appeared bland. We saw that people had access to drinks and snacks throughout the day. People were not always provided with appropriate assistance with their meals.
Decision specific mental capacity assessments had not been carried out where there had been a concern identified about a person’s capacity. The service had made a decision relating to a person’s care and treatment and not acted in accordance with the Mental Capacity Act.
Staff told us that they felt well supported in their roles. However, they had not received sufficient training at the service to enable them to fulfil their roles. Staff had a good understanding of how through their work they were able to respect people’s privacy and dignity and promote their independence.
Quality assurance systems that were in place had failed to identify the concerns that we found and did not identify or manage risks associated with the environment. Records were not completed accurately or stored securely to ensure that information was kept safe.
We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.
During our inspection we spoke with the acting manager, two directors, a senior care worker, a care worker, two kitchen staff and the activity coordinator. We looked at some of the records held in the service, including the care files for five people who used the service.
We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask. This is a summary of what we found.
Is the service safe?
People told us that they felt safe and that staff supported them appropriately.
We saw people had received a pre-assessment, and care plans and risk assessments were in place and reviewed regularly. These meant risks had been identified, and measures were in place to reduce risks and keep people safe.
People had their dependency needs assessed which informed the level of staff required, to meet people's needs and keep people safe. We saw the staff roster showed there was sufficient staff employed and deployed appropriately.
We, the Care Quality Commission (CQC) monitor the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. This means that when people have their liberty deprived in order to keep them safe, this was only done following a best interest assessment carried out by the local authority DoLS team. We saw an authorisation was in place for one person. This showed the provider had acted appropriately and within the legislation.
Is the service effective?
The provider told us, and records confirmed, changes were in place to formally gain people's consent to care and support.
We saw people's preferences, routines, health and welfare needs had been assessed. We saw examples of referrals and joint working with health professionals in meeting people's needs. This showed person centred approaches to care delivery.
People received balanced and nutritional meals that met their dietary requirements. People received sufficient food and fluid that kept them hydrated.
Is the service responsive?
The provider had a complaints policy and procedure that supported people to know their rights, and what action to take should they wish to complain about the service.
An activity coordinator was employed who provided activities for people. We observed people participated in activities. Activity plans were on display that showed various activities were provided should people wish to participate.
Is the service caring?
We found staff knowledgeable about people's needs, preferences and routines.
Staff were observed to be kind and attentive towards the people they cared for. We observed people who used the service appeared relaxed and at ease with the staff supporting them.
Is the service well-led?
Staff were aware of their roles and responsibilities, this showed good leadership and accountability.
We saw the provider had quality assurance processes to monitor the quality of services provided to people. We found these were up to date in accordance to the provider's systems and processes in place.
One person who used the service told us, "I'm very comfortable here. All of the staff are very kind to me." Another person told us, "I have a nice big room. It's nice to be waited on. I feel comfortable and save." Both people told us that they were able to exercise choices about how they spent their time. One told us, "I spend my time how I want. I go to bed when I want. I get a choice of what I'd like to eat at mealtimes." Another told us, "I can eat in my room if I want. the food is excellent. it couldn't be better." Both people knew about social and individual activities that were available. A relative told us, "I'm happy with the care my mother receives. The staff obviously care for her as an individual and that is very important to her."
A social care professional told us that their client had told them that they "couldn't have wished for a better place." They told us that they saw that staff treated people with respect and dignity. They added, "The home is a pleasant environment. My client is happy here. They wouldn't stay here otherwise."
We saw found that people were supported in a caring and courteous manner by staff who had received relevant training.
People told us that they knew about activities that were available to them and that they had always had a choice of whether to participate in activities. We saw that people had exercised choices about how they spent their time and many people had engaged in meaningful occupation either alone or with other people.
People were supported by suitably qualified and experienced staff. The registered manager and senior staff from the provider's head office had carried out regular monitoring of the care, treatment and support that people experienced.
Some people told us they would have liked more to do in the home, as they were sometimes bored with little to occupy their time.