Archived: Kingswood Home

Updated 8 April 2020

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 Care Act 2014.

Inspection team

The inspection was undertaken by three inspectors.

Service and service type

Kingswood Home is a ‘care home’. 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.

The provider of the service was also registered as the manager with the Care Quality Commission. This means that they 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 an unannounced, responsive inspection.

What we did before the inspection

CQC was alerted about serious concerns at the home which occurred over the weekend before the inspection took place. This inspection was brought forward due to information of concern regarding incidents of neglect and serious harm to people that had been raised to CQC by social services, health professionals and police. The information shared with CQC about specific incidents indicated potential concerns about the management of people’s nutrition and hydration needs, hygiene and cleanliness, environmental health and management of people’s health needs. Information about specific incidents highlighted potential serious concerns about delays in staff recognising an acute deterioration in people’s health and seeking timely medical attention. We looked at these concerns in detail during the inspection.

We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections.

During the inspection

We spoke with three people living at the home and one relative about their experience of the care provided. We spent time observing people and how they were supported by staff. We spoke with the provider/nominated individual who was also the registered manager. We spoke with two chefs, two team leaders (one of whom commenced employment on the second day of inspection), two care staff and a number of health and social care professionals who were present at the home during the inspection. We looked at 10 care plans and ‘pathway tracked’ four people. Pathway tracking is a way of understanding how people are cared for, through observations, looking at their care plans and interviewing staff who support these people and how these processes are joined-up. We looked at daily monitoring charts such as food and fluid intake, continence and repositioning records. We also looked at records in relation to the management of the home. Due to focusing on concerns identified before and at inspection, not all key lines of enquiry (KLOEs) were followed-up at this inspection.

After the inspection

As result of issues identified before the inspection, as well as concerns found during the inspection, we sought assurance from the provider that people were safe living at the home. The provider sent us an action plan which described what steps they would take immediately to ensure people’s safety. The provider’s action plan failed to accurately reflect how they would immediately act to keep people safe at Kingswood Home. As a result, CQC used its urgent enforcement powers to safeguard people from the risk of harm. Please see the ‘Enforcement Actions’ section at the back of this report for the full details of our regulatory action.

Updated 8 April 2020

About the service

Kingswood Home is a residential care home providing personal care to 20 people at the time of the inspection. People had a range of health and support needs and included people living with dementia. The service can support up to 23 people.

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

People were not safe living at Kingswood Home. At the time of the inspection, a team of local authority social care professionals had been brought in to assess people’s care and support needs, with a view to moving them into other care homes. People were at risk of receiving unsafe care. Staff had not ensured people had sufficient to eat or drink and their needs were not effectively monitored. Staffing levels were unsafe and meant that people did not have the support or care at the time they needed it. People were not protected from the risk of neglect or abuse. One person who was at risk of choking was given the wrong texture of food which increased their risk of choking. Another person, who was at risk of skin breakdown, was not repositioned regularly according to monitoring records. Medicines were not always managed safely. Stocks of medicines did not tally with records to confirm that people received their medicines as prescribed. There was a strong smell of urine in some parts of the home indicating that cleanliness and hygiene standards were not maintained.

Staff had not completed all the training they needed to ensure people received appropriate care and support. Where training had been completed, staff demonstrated a lack of understanding in key areas, such as safeguarding and types of abuse. People were not always given the correct consistency of food, in line with their assessed risks. Some people presented as being very hungry or thirsty. Drinks were not freely available and people often had to wait for their drinks to be served at set times dictated by staff.

Because of the lack of staff available, people received a poor standard of care. They were not treated with dignity and respect. Care was not personalised to meet people’s needs. Care plans were detailed and provided information about people’s likes, dislikes and preferences, including their interests. However, there was a lack of activities to provide mental stimulation or to engage people.

The culture of the home was negative and staff were dissatisfied working there; some staff felt the registered manager did not listen to them and was not supportive. The registered manager demonstrated poor oversight and capability in their management of the home and of their legal responsibilities. A system of audits had been implemented but was not effective in identifying all the issues found at the inspection or by external professionals who had intervened at the service.

By the end of the third day of inspection, all service users had been moved from Kingswood Home to alternative care placements.

Due to the nature of this urgent responsive inspection and the enforcement action which proceeded it, we were not able to fully answer all of Key Lines of Enquiry (KLOEs) in this report. The report has, instead, focussed on the KLOEs of highest significance to people’s safety, care and welfare.

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, (report published 24 April 2019).

At this inspection not enough improvement had been made and the overall rating has deteriorated to Inadequate.

Why we inspected

The inspection was prompted due to serious concerns received about people’s safety and poor quality of care people had received. In response to these concerns, CQC inspected Kingswood Home as a matter of urgency. Prior to the inspection, we were notified of an incident whereby a person using the service had died. Since the inspection, another person died in hospital. These incidents, as well as concerns about neglect of other Kingswood Home residents, is subject to safeguarding and criminal investigations. As a result, this inspection did not examine the specific circumstances of these incidents. .

Enforcement

We have taken urgent action to safeguard people from the risk of harm. Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded. Please see the ‘Enforcement Actions’ section at the back of this report.

Follow up

For more details, please see the full report which is on the CQC website at www.cqc.org.uk