This unannounced comprehensive inspection was carried out on the 30 October 2018. The last inspection was on 22 January 2018 and was focused on reviewing the actions taken by the provider to address the warning notice which was issued after the last comprehensive inspection carried out on the 3 and 9 October 2017. The service has been rated Requires Improvement following the last three inspections. Kenwyn had made improvements and was rated as Good at this inspection.

At the last comprehensive inspection on 3 and 9 October 2017, we had concerns about medicines management. People did not always receive their prescribed medicines in a timely manner, or as prescribed. Medicine records were not always accurate. Nursing staff did not follow the choking protocol when a person choked at the service. Identified specific risks to people living at the service were not always reviewed and updated in a timely manner. We issued a requirement action against the provider for a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) 2014.

The action plan sent to the Care Quality Commission (CQC) following the previous inspection, had not been effectively put in to place or monitored and omissions and errors continued to occur. Complaints from healthcare professionals and families of people living at the service were not always satisfactorily resolved. Records relating to Deprivation of Liberty Safeguards (DoLS) authorisations held at the service were not accurate. Care plans did not provide clear guidance and direction for staff. Records relating to the provision of commissioned one to one support had not been kept by staff. This meant it was not possible to establish if the commissioned care had been provided. We took enforcement action against the service as a result of the repeated breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) 2014 and issued a warning notice.

At the focused inspection on 22 January 2018 we reviewed the actions taken to meet the requirements of the warning notice. We inspected only the Safe and Well Led sections at that time. Weekly and monthly medicines audits were being carried out on all areas of medicines administration and management and these were effectively identifying when errors occurred. However, medicine errors continued to take place. Three medicine errors had been reported since the last inspection. This led to a continued breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) 2014.

Risks in relation to people's daily lives were identified, assessed and planned to minimise the risk of harm. However, some guidance was not always sufficient to guide staff to reduce risks effectively. Staff were being injured by one person's behaviour that challenged. Agreed action had not been taken to record such events, and specific guidance was not provided to staff to help reduce such events in the future. Whilst the service had met the specific concerns in the warning notice, further concerns were identified which led to a continued breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) 2014. The service had been commissioned to provide 12 hours a week of one to one support with activities for one person. This had not been recorded as having always taken place. This meant this person was not having the activity levels provided as commissioned by the local authority. Staff did not have the skills and knowledge to meet this person's needs. We issued a requirement notice to the provider for a breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) 2014.

Due to the repeated nature of concerns found at the past three inspections a condition was applied to the registration certificate of the service. This condition states that the provider must report to the CQC bi-monthly on the action it has taken to address the repeated concerns found at the last three insp

This unannounced focused inspection took place on 22 January 2018. The last inspection took place on 3 and 9 October 2017 when the service was not meeting the legal requirements. There were two breaches of the regulations. This was because the arrangements in place for the administration and management of medicines at the service were not robust. Three medicine errors had been reported since the last inspection of 03 and 09 October 2017, two for similar concerns and which took place close together. This meant effective action had not been taken following the first event, in order to prevent a second event occurring. People did not always receive their medicines as prescribed due to a lack of stock held at the service. Medicine audits were not effectively identifying when errors or omissions took place. We were concerned that nurses did not always follow the service’s policies and procedures when events took place. Information held by the service regarding the number of Deprivation of Liberty Safeguards authorisations was not accurate. People did not always receive care that was personalised and responsive to their changing needs. Concerns found at previous inspections were not always effectively addressed. Breaches of the regulations continued to remain despite the service providing CQC with action plans laying out the actions they were to take to address issues.

The service was rated as Requires Improvement at that time. Following this inspection the service remains Requires Improvement. Following the last inspection the service sent us an action plan stating the actions it was taking to meet the legal requirements of the regulations. This focused inspection was carried out to check they had followed their action plan and to confirm they now met the legal requirements. This report only covers our findings in relation to the Safe and Well led domains. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Kenwyn on our website at www.cqc.org.uk

People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Kenwyn is a care home which offers nursing care and support for up to 109 predominantly older people. At the time of the inspection there were 80 people living at the service. Some people were living with physical disabilities, long term physical health and mental health conditions including dementia. The service occupies a large detached building over two floors. The service is divided in to four units providing different levels of care to people according to their needs.

The service had reported two further medicine errors since the last inspection. A third took place days before this inspection. The nurse did not follow the service policy to seek medical advice or contact the person’s family following the error. There were systems in place for the management and administration of medicines. Recently implemented weekly and monthly medicines audits were being carried out on all areas of medicines administration and management and these were effectively identifying when errors occurred. Audits looked at areas such as daily stock tallies, stock balances carried forward, self-administration assessments and the signatures on medicine records. The most recent medicine error was identified by the next shift, after the error occurred, due to nurses counting medicines at every medicine round.

Risks in relation to people’s daily lives were identified, assessed and planned to minimise the risk of harm whilst helping people to be as independent as possible. However, some guidance was not always sufficient to guide staff to reduce risks effectively.

Lessons were not always being learnt by the service following events that took place. One person had been identified as having behaviour that challenged staff, agreed act

This responsive comprehensive inspection took place on 3 and 9 October 2017. The first visit was unannounced, the second visit was announced. Concerns were received by the Care Quality Commission and Cornwall Council safeguarding unit from the service about medicine errors which had occurred at the service. There had also been concerns raised by the public and healthcare professionals that some people had not always had their care needs met and their concerns had not always been resolved to their satisfaction.

The last inspection took place on 4 and 10 October 2016. There were two breaches of the regulations found at this inspection. We were concerned that medicines management was not always safe and that regular medicine audits and checks had not identified the concerns found at the inspection. We found that care plans were not always updated to take account of people’s changing needs. The registered manager had not appropriately recorded an investigation into a medicine error. This meant it was not possible to establish the details of all decisions made to help ensure a re-occurrence of such events did not take place in the future.

Following the inspection in October 2016 the provider sent the Care Quality Commission an action plan outlining how they would address the identified breaches. We carried out this inspection in response to concerns raised and to check on the actions taken by the service to meet the requirements of the regulations.

Kenwyn is a nursing home which offers care and support for up to 109 people. At the time of the inspection there were 96 people living at the service. Some people were living with physical disabilities, long term physical health and mental health conditions including dementia. The service is made up of a large detached building over two floors. The service was divided in to four units.

We walked around the service which appeared clean, comfortable and found that there were no incontinence odours. People’s rooms were personalised to reflect people’s individual tastes. People’s choices were respected.

Systems for the management and administration of medicines were not robust. Three medicine errors had been identified by the service since the last inspection. Two errors, which occurred a week apart, involved two people not having their prescribed pain relief given to them. This was because the service did not have sufficient stock.

We found during this inspection further concerns regarding the safe management and administration of people’s medicines. Three people were found to have not received their medicines as prescribed.

Regular medicines audits and ‘resident of the day’ checks were not consistently identifying when errors and omissions occurred. 'Resident of the day' was a system when a named person was chosen daily for a full review of all aspects of their care including their medicines. Recent support and training provided to all the nurses had not been effective in addressing the medicine concerns found at this inspection.

Nursing staff did not always follow the service's policies. For example, the specific action to take when a person choked. The registered manager was investigating an incident where a person had choked and did not receive the care and treatment from a nurse as set out in the service policy.

Staff were supported by a system of induction training, supervision and appraisals. People were supported by staff who knew how to recognise abuse and how to respond to concerns. Risks in relation to people’s care and support needs were mostly assessed and planned for to minimise the risk of harm. These risks were regularly reviewed to take account of changes in people’s care needs. One person’s care plan did not contain required risk assessments to help protect them from the risk of abuse from another person.

Staff received training relevant for their role and there were good opportunities for on-going training and support and development. More specialised tr

We carried out this unannounced comprehensive inspection on 4 and 10 October 2016. Prior to this inspection the Care Quality Commission received information of concern relating to people not always receiving their prescribed medicines safely. The last comprehensive inspection was on 12 January 2016. The service was meeting the legal requirements at that time.

Kenwyn is a care home which provides nursing care for up to 109 people. At the time of this inspection there were 100 people living at the service. Some people were living with physical disabilities, long term physical health and mental health conditions including dementia. The service made up of a large detached building over two floors. The service was divided in to four units.

There was a registered manager in post. 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.

The registered manager had carried out an investigation into the concerns raised about medicines management at Kenwyn. The report stated, “We will continue to monitor medicines management closely to ensure robust systems are in place.” However, the registered manager had not documented interviews with key staff which had taken place as part of the investigation.

There had been a robust audit of medicines management at Kenwyn at the beginning of August 2016. There were some issues found at this audit which needed to be addressed. We found these issues had continued to occur and were found at this inspection visit. This meant the management team at Kenwyn had not taken effective action to address the concerns identified by the audit.

At this inspection we found there were some concerns with the recording practices of staff when receiving, recording and administering medicines. Handwritten entries on to the medicines administration record (MAR) following verbal instructions from a medical practitioner, were not always signed by two staff to reduce the risk of any errors. Out of 15 staff who administered medicines, 11 had been provided with appropriate training and regular updates. We were assured by the registered manager, that the four staff who required an update would be addressed immediately.

Risks to people living at the service were identified and assessed. However, risk assessments were not always updated to take account of any changes to people’s needs. This meant that the risk assessment records for some people were not accurate.

Staff were clear on how to report any safeguarding concerns they may have. The service had raised safeguarding alerts to the local authority appropriately in the past. Staff were confident that any concerns raised would be listened to and action would be taken to protect vulnerable people.

Kenwyn was fully staffed at the time of this inspection. There were sufficient numbers of staff to meet the needs of people living at the service. Short notice absence, such as staff sickness, was covered by agency staff where possible.

Activities were provided for people by a dedicated activities team who worked in the service seven days a week. Some people were supported to go out in to the local community to take part in activities they enjoyed.

Care plans held clear information and guidance for staff on how to meet an individuals care and support needs. Reviews of people's care plans took place regularly. However, they were not always updated in a timely manner to help ensure they were accurate and up to date following any change in a person's needs. Such changes were not always clearly recorded on handover records. This meant that staff may not always be made aware of a change in a person's care needs.

Staff told us they found the management team approachable and supportive. Staff were pro

This unannounced comprehensive inspection took place on 12 January 2016. The last inspection took place on 2 June 2014, the service was meeting the legal requirements of the legislation at that time.

Kenwyn is a nursing home which offers care and support for up to 109 people. At the time of the inspection there were 97 people living at the service. Some people were living with physical disabilities, long term physical health and mental health conditions including dementia. The service comprises of a large detached building over two floors. The service was divided up in to four units.

The service had a registered manager in post. 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.

We walked around the service which was warm and comfortable. Bedrooms were personalised to reflect people’s individual tastes. People were treated with kindness and respect.

We looked at how medicines were managed and administered. We found it was always possible to establish if people had received their medicine as prescribed. Regular medicines audits were consistently identifying when errors occurred.

The service had identified the minimum numbers of staff required to meet people’s needs and these were being met.

Staff were supported by a system of induction training, supervision and appraisals. However, staff were not receiving supervision according to the policy held at the service, which stated staff should be supervised four times a year. More specialised training specific to the needs of people using the service was being provided, such as dementia care. Staff meetings were held regularly. These allowed staff to air any concerns or suggestions they had regarding the running of the service.

Meals were appetising and people were offered a choice in line with their dietary requirements and preferences. Where necessary staff monitored what people ate to help ensure they stayed healthy.

Care plans were well organised and contained accurate and up to date information. Care planning was reviewed regularly and people’s changing needs recorded. Where appropriate, relatives were included in the reviews.

There were staff dedicated to providing 80 hours a week of activities for people at the service. However, the activities provided were not meaningful and relevant to people’s specific interests and abilities.

The registered manager was supported by a deputy manager and senior staff from the four units at the service. The provider supported the management team with regular visits from the area managers.

We considered our inspection findings to answer our five questions; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, the staff supporting them and looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

At the time of our inspection we found the service was safe because people’s rights and dignity were respected and they were involved in decision making about risks.

People told us they felt safe living at the home and with the staff.

We saw that risks to people had been assessed and plans were in place to minimise any risks.

People’s care and support monitoring records were completed and regularly reviewed to ensure they received the right care and support.

Staff were trained in safeguarding and knew how to report any allegations of abuse.

Staff were aware of the Mental Capacity Act 2005 and how to involve appropriate people, such as relatives and professionals, in the decision making process if someone lacked the mental capacity to make a decision.

CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguard (DOLs). We found the service to be meeting the requirements of the legislation. Applications had been submitted appropriately, policies and procedures were in place and we found staff to be well informed.

Systems were in place to make sure that managers and staff learnt from events such as accidents and incidents, complaints and concerns. This reduced the risks to people and helped to continually improve the service.

Is the service effective?At the time of our inspection we found the service was effectively meeting the needs of all the people who used the service. Staff had a good understanding of people’s needs and responded to changes in their needs in a timely way.

People told us “it is very good here”, “we have a choice of menu and food is excellent”, “they give us a list of things we can do each day” and “you get privacy if you want it.” People told us they could go to bed and get up whenever they chose.

People, or their representatives were involved in their assessments and developing their care plans.

People received appropriate support from healthcare professionals when required.

Newly appointed staff received an induction prior to starting work which included a period of shadowing more experienced staff and a probationary period of three months.

People’s end of life wishes had been planned for. People and their relatives told us they were involved in decision making. We saw evidence of advocacy services being used to support people where they did not have any family or representatives and required support in making some decisions.

The premises had been sensitively adapted to meet the needs of people with physical impairments.

Is the service caring?

At the time of our inspection we found the service to be caring as people were treated with dignity and respect and were listened to.

People spoke positively about the care they received and that staff were kind, caring and compassionate. One person told us “I really rate it “and “The staff know me really well, I don’t like going to bed and that’s ok.”

People’s privacy and dignity was always maintained. We saw staff maintained people’s dignity during personal care and during moving and handling.

We saw people’s preferences and dislikes were clearly recorded and respected. Life histories were recorded along with lifestyle choices, this meant staff had all the information to be able to care for and support people as individuals.

Is the service responsive?

At the time of our inspection we found people received a service that responded to their needs. We saw people had their capacity assessed in relation to making decisions, and best interest decisions were made in consultation with relatives, staff and professionals.

We saw a GP from the local practice had been asked to see a person who was unwell. They told us “They always call us appropriately and in a timely way, they are pretty good.”

People told us they had access to call bells when they required assistance. We were told by most people the staff responded quickly, but one person told us “Staff don’t always come as quickly as I would like when I ring the call bell but they are usually tied up with someone else.” This person told us this happened occasionally and it was usually due to staff being required to assist another person who was unwell. This person told us “staff levels have improved recently and it has not happened for a while.”

Kenwyn had two activity co-ordinators who planned and organised activities throughout the four units of the home. We saw some evidence of people receiving 1:1 activities in their rooms. Staff told us they enjoyed spending time with people having a chat or encouraging them with some activity.

We saw the complaints procedure was available to people. Many compliments and thank you cards had been received by the home, praising the care received.

People’s views and experiences of the service were sought and any issues were responded to promptly.

Is the service well – led?

At the time of our inspection we found the service was well-led, staff told us the registered manager was approachable, supportive and had made a real difference to the service.

Observations and feedback from people, relatives, staff and visiting professionals was that the culture of the home had improved and become more open and transparent. This was because people, relatives and staff said they felt listened to by the manager and that action was taken when they raised concerns.

The management had systems in place to assess and monitor the service provided.

There were robust systems in place to monitor the safety of the building and equipment.

Staff had begun to receive regular supervision and appraisals.

Kenwyn provided care and support to a maximum of 109 people. The home had four units. Two accommodating people who needed nursing or personal care (Trellisick & Pencarrow), one for people who needed nursing or personal care and also had a form of dementia (Tresco) and one for people with physical disabilities who needed nursing or personal care (Glendurgan).

There were 80 people using the service at the time of our inspection, 42 on Trellisick and Pencarrow, 32 on Tresco and 12 on Glendurgan.

We saw people’s privacy and dignity were being maintained. People we spoke with told us ”they treat me okay really, they close the doors and curtains, that's good and use my name when helping me”, “ they talk to me, we have a conversation” and “They always make sure the room is warm and close the doors when caring for me”. Another person told us “they wake me up, always eight o'clock, they won't let me sleep”. This person did not know they could sleep in if they wished to.

We saw care plans were detailed and generally gave direction to staff as to the care and support people needed. They had been regularly reviewed. We saw they were not always developed and reviewed with the person using the service and /or their relatives where appropriate.

People were protected from the risks of inadequate nutrition and dehydration.

There were enough qualified, skilled and experienced staff to meet people’s personal care and nursing needs. We noted some training needs around the management of specialist diets.

We saw evidence of on-going audit in areas including medicines management, complaints and health and safety. Results of satisfaction surveys were shared with people who used the service and their representatives. Notifications had not always been submitted to the Care Quality Commission in a timely fashion.

During this inspection we reviewed the work that had been carried out by the provider, as a response to the inspection carried out in March 2013.

We spoke with the provider, registered manager, area manager, staff, and one person who lived at the home. Most of the people who lived at Kenwyn were unable to comment on the care they received, we therefore observed how staff assisted them throughout the day whilst we reviewed the records.

We saw that there were adequate staff to meet the needs of the people that lived at Kenwyn, in a relaxed and dignified manner.

The care plans had recently been reviewed and/or rewritten to ensure that staff were directed on how to care for a person in a clear and concise way.

People’s meal choices and dietary requirements had been gathered and there were snacks and drinks available throughout the day.

Care staff assisted people with meals in a timely manner and staff interaction during these times had improved since our previous visit to the home.

Training had taken place on issues regarding nutrition and hydration. This meant that staff were aware of their responsibilities and the importance of the overall dining experience.

During this inspection we saw a number of improvements made by the provider, manager and staff. We will continue to monitor Kenwyn to ensure that the recent improvements and new processes have been sustained.

Kenwyn nursing home was divided into four units. During the inspection we walked around the whole home and then looked at the documentation and spoke to the staff on one unit.

The staff demonstrated a good knowledge of the care needs of the people that lived at Kenwyn nursing home. Care plans did not always reflect the needs of the people that lived at the home.

People were seen to take part in a number of activities. The manager told us that they would be recruiting more staff in order to provide more activities.

We saw and heard most people being offered choices and treated with respect, However care workers were seen not to interact well with the people they were assisting with their lunch time meal.

Following our visit on 1 July 2011 the service provided us with a detailed action plan about how they were going meet the improvement actions. We carried out this follow up visit on 2 November 2011. We visited Tresco Unit, which accommodates people with dementia, only as this is the area we had concerns about and made improvement actions for. We also had an anonymous concern raised with us in mid October 2011 relating to Tresco Unit.

We observed staff spending time with people who use the service either talking or engaged in individual activities. This included asking what they would like to do that afternoon, discussing what they had had for lunch and if they had enjoyed it and staff walking with people around the unit helping them to decide how they would like to spend some time.

One person said they have choices about what they would like to eat and how they spend their time.

A number of people were seen sitting at the tables in the dining rooms following their lunch, some enjoying a glass of wine. They were talking amongst themselves and with staff.

During a tour of the home hostess and care staff were seen serving meals and drinks and care staff were seen supporting people who required some help.

We saw that people are encouraged to eat their meal in either of the two dining areas and that the meals are served at the table from a hot trolley. The tables were well laid, with table clothes and table decorations, and some people had the option of wine with their meal.

We saw some people using the communal areas of the home engaging with each other and members of staff. People were able to move around the communal areas easily and had access to outside space if they wanted to go out.

We were told that the staff are very helpful, polite and attentive although busy and don’t therefore have much time to chat. We were told by a relative that people were treated with respect and dignity and that everything is explained to them and their relative (where appropriate) prior to anything being carried out or if any changes to their care are needed.

People said the meals are ‘always good’ and that there is ‘plenty of choice’. One person said that if they decide to eat in their room that day they do not get to see the menu in advance. We observed that some people have to wait for some time for the help they need to eat their meal. We were also told that the home is ‘always clean’ and that cleaning staff clean their rooms ‘each day’.

People said they felt ’safe’ and ‘well supported’ and were happy living at Kenwyn. We were told that they knew who to speak to if they were worried about their safety or had any complaints or concerns. Those that had minor concerns said that they could ‘speak to someone in the home who would sort it out’ and if they didn’t they would ‘speak directly to the manager’.

They told us that they knew the difference between the different staff groups by their uniforms and the help they give them.

The people that lived at Kenwyn did not receive care that was appropriate to their individual needs. The care plans were inconsistent and did not ensure the care and welfare of people at all times.

People that had been assessed as at risk of malnutrition and/or dehydration were not effectively monitored. Food and fluid charts were not completed consistently and people were not weighed in line with their care plan.

People that used the service were not protected from the risks of inadequate nutrition and dehydration.

Staff felt supported by the heads of department, managers and nurses. Formal supervisions had commenced for care staff and nurses.

Training was provided to new staff within a week of them commencing work within the home, this included manual handling, infection control and safeguarding. Most staff had completed safeguarding of vulnerable adults and manual handling training.

There was not an effective system in place to regularly monitor the service and to respond to any issues or concerns that were raised.