Kingswood House Nursing Home

Updated 30 June 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 Care Act 2014.

As part of this inspection we looked at the infection control and prevention measures in place. 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 carried out by two inspectors who visited the service.

Service and service type

Kingswood House 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 service did not have a manager registered with the Care Quality Commission. This means that the provider is 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 inspection

We reviewed information we had received from, and about, the service since the last inspection and we sought feedback from the local authority. We used all of this information to plan our inspection.

The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report.

During the inspection

We spoke with eight people who used the service, about their experience of the care provided. Not everyone who lived at Kingswood House wished to talk with us about their views, so we spent time observing how people and staff interacted and how people spent their time at the home. We observed administration of medicine. We spoke with eight members of staff including the manager, area manager, deputy managers and care staff.

We reviewed a range of management records including safety and maintenance records and audits. We reviewed eight people’s care and support records. We looked at records in relation to staff training and staff supervision.

We continued to seek clarification from the manager to validate evidence found. We spoke with two visiting professionals and a member of the local authority commissioning team. We also received further feedback from two members of staff.

Updated 30 June 2022

About the service

Kingswood House Nursing Home is a residential care home providing personal and nursing care for up to 22 younger adults who have mental health needs. There were 19 people living there at the time of the inspection. Most people needed support with mental health needs and some people lived with complex health needs, such as Huntington’s chorea. Some people also received rehabilitation support which prepares them for returning to independent living.

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

Systems and processes to assess, monitor and improve the quality and safety of the service provided were in place. However, there were areas of people’s documentation that needed to be improved to ensure staff had the necessary up to date information to provide consistent, safe care. Incident forms were completed but there was a lack of overview, analysis and follow up to prevent a re-occurrence or to mitigate risk. Notifications of incidents and events had not been reported to CQC as legally required for the service since July 2021.

Improvements were needed to the management of risk to ensure people received safe care and support. Incidents and accidents whilst recorded on an incident form were not reflected in peoples’ care plans. There was no analysis of cause, trends or themes, therefore, opportunities of learning from accidents and incidents had been missed. Staff were not monitoring the overall effectiveness of pain relief medicine or looking at the times as and when needed medicine (PRN) requests were made for trends or themes.

People received support from staff who had been appropriately recruited, and trained to recognise signs of abuse or risk. One person said, “I am safer here than anywhere.” Medicines were being given to people by trained and knowledgeable staff, who had been assessed as competent. There were enough staff to meet people's needs. Safe recruitment practices had been followed before staff started working at the service. The home was clean and hygienic.

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.

People, their relatives and health care professionals had the opportunity to share their views about the service. The provider and manager were committed to continuously improve and had developed structures and plans to develop and consistently drive improvement within 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 update:

The last rating for this service was Requires Improvement (published 4 February 2020)

Why we inspected

The inspection was prompted in part due to concerns received about the management of incidents and potential under reporting. A decision was made for us to inspect and examine those risks. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

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.

The overall rating for the service has changed from Good to Requires Improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report.

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 monitor the service and will take further action if needed.

We have identified breaches in relation to management of risk, and good governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.