Kenilworth Grange Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

This is the first assessment for this newly registered service. This key question has been rated good.

This meant people were safe and protected from avoidable harm.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always shared to continually identify and embed good practice.

Some relatives told us that when they had raised concerns, these had not always been responded to effectively. Not all concerns raised had been documented as complaints, and this limited the provider’s opportunities to monitor trends and drive improvements in the home.

When incidents had happened in the home, such as falls or deterioration in people’s skin, leaders had analysed the cause and looked at ways to prevent re-occurrence. However, improvements needed to be made to ensure all staff were aware of learning practices. The provider took action to improve information sharing during our inspection.

Staff told us there was a positive and open approach to learning from any mistakes or adverse incidents to improve their individual practice. One staff member told us, "We definitely try to take action straightaway if something goes wrong. We have a meeting with the manager or deputy manager and we have emails." Another staff member told us staff were supported in relation to individual mistakes. They explained, “I didn’t correctly use the equipment and my manager spoke to me about it and suggested I went on a training session. There are things put in place when you are doing things wrong that help you."

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The home was commissioned to care for some people as part of a ‘discharge to assess scheme.’ This is when people are fit to be discharged from hospital but need further monitoring and support before making decisions about their future care. Staff in the home worked closely with the hospital team, and a range of healthcare professionals to ensure safe transitions into the home, and ongoing monitoring during their stay. Some people and their relatives told us communication about how the scheme worked needed to be improved. Staff had put together a welcome pack which gave people information about what to expect.

The provider followed the “red bag scheme” which is a pathway of care for people in care homes who require hospital treatment. The bag contains essential items for a hospital visit including information about the person’s medicines and allergies and any support they needed with eating, drinking and moving around safely. This ensured people’s needs could continue to be met during a transition between services. Records were prepared and available if people needed to be transferred to hospital in an emergency. These records were regularly reviewed to ensure the information about people’s needs remained accurate.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. The provider shared concerns quickly and appropriately.

People told us they felt safe living at Kenilworth Grange.

Most staff demonstrated a good understanding of their responsibility to keep people safe from abuse, harm or discrimination. They knew how to report any safety issues to managers and senior staff and told us they would escalate concerns if they had not been appropriately dealt with. One staff member said, “I am very strict with this (safeguarding) because at the end of the day we are here to respect our residents and to the highest quality as possible." Most staff were aware of the provider’s whistleblowing policy with 1 staff member commenting, “The information is everywhere. The main one is in the staff room downstairs, but the posters are pretty much around the home." However, a few staff did not demonstrate the same confidence and were not clear about who to speak to if they could not report their concerns to leaders in the home. The provider gave us assurances they would work to further develop all staff’s understanding in this area.

The registered manager understood their responsibility to report any safeguarding concerns to the local authority and us, CQC. Records demonstrated information had been shared appropriately to investigate and address any safeguarding referrals raised.

When receiving care and treatment, people can only be deprived of their liberty with the appropriate legal authority. In care homes, this can be done through a procedure called The Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act (MCA) 2005. We checked how the provider managed DoLS within the home. Where people had restrictions in their care plans that they had been assessed as not having the capacity to consent to, the provider ensured DoLS applications had been submitted to the relevant supervising body.

Staff had received training in safeguarding, the Equality Act 2010 and the Mental Capacity Act 2005.

The provider did not always work effectively with people to understand and manage the risks to their health and wellbeing.

We found examples where people’s needs were not consistently recognised or acted on in a timely way. This meant risks were not always reduced as planned. For example, one person required regular repositioning to prevent skin damage, but records showed this was not carried out as specified in their care plan. This increased the risk of avoidable pressure injury.

Several people required close monitoring of their fluid intake, but monitoring records did not reliably demonstrate that people were drinking enough to meet their daily recommended targets, or in some cases, that they had been offered sufficient fluids over a 24 hour period. This meant staff did not always have the information needed to identify early signs of deterioration or take action to prevent harm.

Some relatives told us their family member spent prolonged periods in bed and felt their independence and well being was not always promoted unless they raised concerns. This meant people were not consistently supported to mobilise or spend time out of bed in line with what mattered to them.

Despite the shortfalls, we saw occasions where people were supported to take positive, meaningful risks that enhanced their quality of life. Care plans were otherwise detailed and included clear clinical risk assessments, such as for catheter care or tube-fed nutrition. We saw examples where guidance helped staff respond safely when a person became anxious or distressed. Where people lacked capacity, best interest decisions were documented and showed that least restrictive options had been explored.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

People were invited to personalise their bedroom. Information was shared with people on admission which guided them on regulations and standards furniture and equipment needed to meet, to ensure it was safe to be used in the home.

The provider ensured relevant safety checks were completed as required in relation to gas, electricity, water, Legionella, and equipment safety.There was evidence of regular maintenance checks being completed on-site. A dedicated maintenance person had oversight of work that needed completing. Safety checks had been completed by external contractors.

Staff were able to tell us what they would do if there was a fire and had received training in fire safety by an external company. Regular fire drills ensured their training was embedded. The provider’s business continuity plan identified what to do in an emergency and highlighted areas of risk.

We observed some areas where decoration could be improved. For example, we saw some scuffed skirting boards and door frames. Leaders told us a refurbishment plan was in place. Staff told us that since being appointed, the registered manager had made some improvements to the home, including a reorganisation of the layout, decoration works and new furniture.

On 2 occasions we found thickener [prescribed to thicken fluids] left accessible to people, posing a risk of choking, and 1 occasion where a door to a sluice had been left unlocked, meaning people had access to chemicals which posed a risk to their health if ingested. The registered manager took immediate action to address these lapses in practice with staff.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

People told us staff were available when they needed them, but at times they were very busy. Comments included, “I have my call bell if I need someone and they usually come within minutes.” Another person told us, “We don’t really have a choice in the mornings of time, staff are always pushed for time, and it’s always busy as everyone wants to get up.” We saw staff were present in communal areas of the home throughout the day, and nurses and leaders supported care staff when necessary.

Staff told us that staffing levels were safe and enabled them to provide care when people needed it. However, 1 staff member acknowledged that it could be more challenging when other staff left the floor to take their breaks. They commented, “Mostly when you are left on your own it is a bit hard to manage everything. That is why we take our breaks when it is less busy."

The registered manager had oversight of rotas in the home, and deployed staff depending on experience and skill level. Records evidenced there were enough staff to meet the needs of people, and the provider monitored this regularly using a dependency tool. There were ancillary staff to maintain a clean environment, provide administrative support, ensure the maintenance of the home and prepare people’s meals and drinks. This allowed clinical and care staff to focus on providing people with safe care.

Systems were in place to check the suitability of staff before they commenced employment. These included obtaining references and Disclosure and Barring Service (DBS) checks. DBS checks provide information including details about convictions and cautions held on the Police National Computer.

Staff completed a 12-week induction programme when they started working at Kenilworth Grange. The induction was aligned to the Care Certificate. The Care Certificate is a set of foundational standards for health workers to ensure they have the necessary skills, knowledge, and behaviours to provide compassionate, high-quality care.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

People and their relatives told us the home was clean and that staff wore appropriate personal protective equipment (PPE) when delivering care. Comments included: “It is a nice home, it’s always clean and tidy” and “They always wear gloves and aprons.”

The provider had recently increased the domestic hours allocated in the home and we saw bedrooms and communal areas of the home were clean and tidy. PPE was available, and staff were seen using and disposing of it in accordance with best practice. Staff were trained in infection prevention and control and were able to describe what processes were in place to keep people safe. Clinical rooms were clean and well maintained.

People who were at greater risk from infection had detailed care plans which told staff what practices they needed to follow to reduce the risks. Domestic staff demonstrated knowledge around different types of infections and precautions they took to promote good infection control.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People told us they received their medicines as prescribed and pain relief was available when they needed it.

There were systems in place to support the safe management of medicines, and medicines were administered as prescribed. Records showed no missed doses, and medicines were labelled correctly. Running balances of medicines were maintained so any discrepancies could be promptly identified. Clinical rooms were organised and medicines were stored safely. Records showed regular temperature checks were made to ensure medicines were kept within the recommended range to maintain their efficacy.

People’s care plans contained detailed information about their medicines.

Medicines were audited regularly and by a variety of staff within the home to ensure systems were effective. Records evidenced that all staff who administered medicines were trained to do so and their competency to understand safe processes was checked regularly.