Background to this inspection
Updated
18 March 2022
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.
As part of this inspection we looked at the infection control and prevention measures in place. This included checking the provider was meeting COVID-19 vaccination requirements. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
Inspection team
The inspection was undertaken by one inspector.
Service and service type
Kenroyal Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and clinical commissioning group (CCG) who commission with the service. We also contacted Healthwatch. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. We used all of this information to plan our inspection.
We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report.
We used all this information to plan our inspection.
During the inspection
We spoke with six people who used the service about their experience of the care provided. We had discussions with seven staff including three nurses, a member of the housekeeping team, a laundry assistant and two care and support workers. We also spoke with the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.
We used the Short Observation Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.
We reviewed a range of records. This included three people’s care records and multiple medication records. We looked at two staff files in relation to recruitment. A variety of records relating to the management of the service, including monitoring of quality and risk, policies and procedures and minutes of meetings were examined.
After the inspection we continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance information.
Updated
18 March 2022
About the service
Kenroyal Nursing Home is a residential care home that can provide long and short-term residential and nursing care for up to 64 older people, including people living with dementia. At the time of our inspection 61 people were using the service.
People’s experience of using this service and what we found
Improvements had been made to the risk management systems in place to ensure people were cared for and supported safely. Environmental checks had been improved so that the service was a safe place to live and work.
Improvements had been made to the medication practices and procedures to make sure people received their medicines as prescribed. Medicines were administered by trained staff and were stored safely.
Infection control processes had been improved to protect people from the spread of infections. Information regarding infections was in place and procedures relating to infection control were consistently followed.
The systems in place to ensure lessons were learnt when things went wrong had been improved. The registered manager had implemented a system to monitor incidents and accidents monthly so action could be taken to promote people’s safety.
The service had improved their governance systems to ensure all aspects of the service and people’s care were continuously assessed and monitored. A range of audits were in place to monitor the quality and safety of service provision.
People we spoke with felt safe living at Kenroyal Nursing Home. There were systems and processes in place to safeguard people from potential harm. Staff completed training about safeguarding people from harm and knew how to report abuse.
There were sufficient numbers of staff to meet people's needs safely. People were supported by regular staff who knew them and their needs well, which promoted continuity of care. The provider had followed their recruitment practices to ensure people employed were suitable to work at the service.
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 and update
The last rating for this service was Requires Improvement (published 2 October 2020) and there were two breaches of regulation.
Why we inspected
We carried out an unannounced focused inspection of this service on 18 August 2020. Two breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve Safe care and treatment and Good Governance.
We undertook this focused inspection to check the provider had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.
The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has improved to Good. 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.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Orchard House Residential Care Home on our website at www.cqc.org.uk.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.