Kingston House

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right Support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

Based on our review of safe, caring and well led. The service was not able to demonstrate how they were meeting some of underpinning principles of 'Right Support, Right Care, Right Culture.'

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

Right Support:

People’s medicines were not always managed safely.

The recruitment checks for new staff were not robust.

People were supported to make decisions by staff who used best practice in decision-making and communicated with people in ways that met their needs.

People’s care and support was provided in a safe, clean environment which met their physical needs. People had a choice about their living environment and were able to personalise their rooms.

People could access health and social care support in the community.

Right care

Staff had not been provided with sufficient guidance on how to protect people from identified risks.

People received¿kind and compassionate care from staff who protected¿and respected¿their privacy and dignity and understood and responded to their individual needs.

The service had enough staff working each day to meet people’s needs and keep them safe.

Staff understood people’s individual communication needs.

People received care and support from staff who knew and understood people well and were responsive to their needs.

Right culture

The provider had not taken the opportunity, since the last inspection, to implement effective change to ensure the service met the regulations, reflected best practice expected by Right Support, Right Care, Right Culture, and offered improved outcomes to people.

There were no effective processes in place for assessing and monitoring the quality of the services provided and to ensure records were accurate and complete. Systems had failed to identify that people were not always protected from avoidable harm.

Systems in the service did not ensure that all the utilities were monitored to ensure safety.

The service involved appropriate professionals in planning people’s care.

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 information, please read the detailed findings section of this report. If you are reading this as a separate summary, the full report can be found on the Care Quality Commission (CQC) website at www.cqc.org.uk

Rating at last inspection and update

At our last inspection we found breaches of the regulations in relation to the management oversight of the service and made a recommendation in respect of the records required when recruiting staff. We have identified 1 continued breach in respect of good governance. We have also identified 2 new breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to safe care and treatment and staffing.

The last rating for this service was Requires Improvement (published 19 October 2022)

Why we inspected

We were prompted to carry out this inspection due to concerns we received about the service. These included concerns that people were not receiving personal care, medicine administration, the culture of the staff and the impact on people they support, unsafe moving and handling, and a lack of support from the management team.

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.

Enforcement

Since the last inspection we recognised that the provider had failed to have oversight of the service, had not ensured appropriate recruitment checks had been made, failed to ensure medicines systems were safe and the provider had not assessed or acted on risks to the health and safety of people receiving care. These are breaches of regulations. Full information about CQC’s regulatory response has been added to the end section of the full version of this report as enforcement action has concluded.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Kingston House is registered care home providing personal care for up to three people with a learning disability. At the time of the inspection there were three people living at the service. The service is based in a detached house over two floors with passenger lifts for people to access the upper floor. The service was equipped with facilities to support the needs of people living at Kingston House.

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

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right Support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

Based on our review of safe, responsive and well led. The service was not able to demonstrate how they were meeting some of underpinning principles of ‘Right Support, Right Care, Right Culture.’

Right support:

Following the recent management changes at the service people were now supported by enough staff on duty, received their medicines in a safe way and were protected from abuse and neglect. People’s care plans and risk assessments were being updated to reflect people’s current support needs so that staff could provide consistent support to people.

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.

Kingston House was spacious and adapted to meet people's changing needs.

Right care:

Following the recent management changes at the service, care plans were now being reviewed and updated to reflect people's changing needs. Staff did not always have the skills or guidance to respond appropriately in risky situations.

People were treated as individuals, their communication styles were respected, and staff understood what worked well for them.

People were treated in a dignified manner. Staff were observed talking to people in a dignified and respectful way. Staff delivered personal care when people needed it and gained consent prior to providing any support.

People were supported to access healthcare services, managers and staff recognised changes in people's health, and sought professional advice appropriately.

Right culture:

The organisation exhibited many of the risk factors associated with closed cultures including; people’s level of dependence on staff for basic needs, reliance on staff support to enable them to access the community, significant changes in leadership of the service and a lack of effective external oversight.

Whole service audits had not been carried out to identify any areas for improvement. Records in the service were limited, for example some recruitment documentation was not available, managers and staff meeting minutes were absent. Therefore, areas for improvement had not been identified and there was no formal action plan to drive forward improvements at the service.

A new acting manager and deputy manager had been appointed and staff and relatives were more confident that the ethos, values and attitudes in how to support people to live meaningful and active lives was improving.

Staff told us there had been a lack of leadership, but this had recently improved with the appointment of the acting manager two months ago.

For more information, please read the detailed findings section of this report. If you are reading this as a separate summary, the full report can be found on the Care Quality Commission (CQC) website at www.cqc.org.uk

Rating at last inspection:

The last rating for this service was Good (published 26 June 2018). We had carried out a focused inspection since then to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively. This inspection was not rated and was published 22 March 2021.

Why we inspected

We were prompted to carry out this inspection due to concerns we received about the culture of the service, staffing and management. A decision was made for us to inspect and examine those risks. As a result, we undertook a focused inspection to review the key questions of safe, responsive and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection. We found no evidence during this inspection that people were at risk of harm from these concerns. Please see the Safe, Responsive and Well led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Kingston House on our website at www.cqc.org.uk

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.

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 found breaches in relation to records, systems and processes at this inspection.

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

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

We found the following examples of good practice.

The service was clean throughout, and there were appropriate procedures to ensure any infection control risks were minimised.

Cleaning and infection control policies and procedures had been updated in line with Covid-19 guidance to help protect people, visitors and staff from the risk of infection. The registered manager kept up to date with appropriate training in infection control. The registered provider arranged and delivered training for staff to ensure they knew how to keep people safe during the COVID-19 pandemic.

The people at the service were shielding and the registered manager had taken this into account as they reviewed the layout of the home, especially the communal areas. People now had access to their own individual living space, as well as bedroom and bathing facilities, and were supported by a dedicated core staff team. This had been discussed with people and the registered manager felt they had responded positively to this change in their environment.

As people had a dedicated staff team, activities were provided that meet the person's interests whilst maintaining people’s safety.

There were sufficient staff on duty to meet people's needs. Staff had covered for any gaps in the rota which meant no agency staff were used throughout the pandemic. The registered manager was mindful of the physical and emotional impact of the pandemic on people at the service, relatives and staff. To support staff, she provided a ‘monthly treat’ for staff e.g. a personalised mug, personalised chocolate, some toiletries and a 'superhero toy' to show the providers appreciation for the support staff have provided to people at the service.

The registered manager was keen to encourage contact with families and had arranged previously for some people to have garden visits. Some relatives were unable to visit the service and the registered manager organised a ‘drive by’ so that the person could see family members at a safe distance at their relatives’ home. Everybody had been provided with an electronic devise to enable them to communicate with family and friends.

The registered manager was communicating with people, staff and family members regularly to make sure everyone understood procedures and precautions being taken, and how to keep people safe.

Clear signage and sanitiser dispensers were in place around the service. They were informative and highlighted what PPE was required to protect people and if any person living in the service was at higher risk.

The registered manager worked with the whole staff team to ensure infection prevention and control measures were in place. This included a review of the staffing areas to ensure that staff could take staggered breaks in a designated and safe area. Staff dedicated changing area included individual storage space for staff clothes and shoes.

Suitable testing routines had been arranged for staff and people who used the service. The registered manager said both staff and people who used the service had been happy to participate in regular testing.

The service had comprehensive policies and procedures in respect of Covid 19 and its implications on the running of the service. From our discussions and observations these had been effectively implemented.

Further information is in the detailed findings below.

The last inspection took place on 4 April 2017. The service was rated as Requires Improvement at that time. There were concerns around how the management team supported staff and how staff responded to each other in front of the people they supported. Since the inspection the operational manager had left the organisation, and there had been a number of staff personnel changes in the home. Staff told us they felt more supported by the managers of the service, and with the staff changes this had led to the staff team working more positively together. One staff member commented “Some staff left, staff personalities are much better now. I enjoy my shift.” The registered manager commented “Staff are aware this is a person home, arguments are left outside. Staff morale is so much better, staff are much happier.”

At this inspection we found improvements had been made in all the areas identified at the previous inspection. This meant the service had met all the outstanding legal requirements from the last inspection. The service is now rated as Good.

Kingston House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Kingston House is a detached home which provides accommodation for three people. The service has environmental adaptations to enable people who use specialist equipment to move freely around their home. At the time of the inspection three people were living at Kingston House. Kingston House is part of Westlake, an organisation providing support and care for people with a learning disability in the Cornwall and Plymouth area.

The care service has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.

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.

On the day of the inspection there was a calm, relaxed and friendly atmosphere in the service. We met with the three people living at Kingston house and spent some time with them and staff. Staff were respectful and caring in their approach. They knew the people they supported well and had an understanding of their needs and preferences. People were treated with kindness, compassion and respect.

Staff ensured people kept in touch with family and friends. Relatives we spoke with told us "They [staff] are brilliant” and “[person’s name] needs are more than well met by brilliant staff.” Relatives told us they were always made welcome and were able to visit at any time.

Staff said they were proud to work at Kingston house and told us “This is our extended family.” We saw a staff member turn to the person they supported and said to them, “We are a team.”

People were protected from abuse and harm because staff understood their safeguarding responsibilities and were able to assess and mitigate any individual risk to a person’s safety.

The service was warm, comfortable and appeared clean with no unpleasant odours. The service was well maintained. People were pleased with their private bedrooms and had decorated them to reflect their preferences and tastes.

The service had suitable arrangements for the storage and disposal of medicines. Medicines were administered by staff who had been trained and assessed as competent to manage medicines. The service held medicines that required cold storage and were stored in the service communal refrigerator. It is recommended that a risk assessment in the storage of medicines in the communal refrigerator to ensure the safe keeping of medicines.

People received care and support that was responsive to their needs because staff were aware of the needs of people who lived at Kingston House. Staff were prompt at recognising if a person’s health needs had changed and sought appropriate medical advice promptly. Relatives told us the service always kept them informed of any changes to people’s health and when healthcare appointments had been made.

Sequence strips and easy read information were used to support effective communication. The care plan identified the person’s communication needs and this was shared with other agencies when necessary.

Care plans were well organised and contained personalised information about the individual person’s needs and wishes. Care planning was reviewed regularly and whenever people’s needs changed. People’s care plans gave direction and guidance for staff to follow to help ensure people received their care and support in the way they wanted. Risks in relation to people’s care and support were assessed and planned for to minimise the risk of harm.

Staff supported people to maintain a balanced diet in line with their dietary needs and preferences. Where people needed assistance with eating and drinking staff provided support appropriate to meet each individual person’s assessed needs.

People were supported to maintain good health, have access to healthcare services and receive on-going healthcare support. The staff had developed positive working relationships with health and social care professionals.

Care records showed that people took part in a range of activities. We saw people undertaking individual activities such as going out for walks with staff, going to the hydrotherapy pool and socialising. On the day of the inspection it was the royal wedding, a person went with staff to buy items for afternoon tea and had invited a friend to come over and join in their celebrations. People and staff watched the royal wedding together and enjoyed this event.

Staff were recruited in a safe way. There were sufficient numbers of suitably qualified staff on duty and staffing levels were adjusted to meet people’s changing needs and wishes.

Staff were supported by a system of induction training, one-to-one supervision and appraisals. The induction and on-going training of staff ensured they were effective in their role. Staff knew how to ensure each person was supported as an individual in a way that did not discriminate against them.

Management and staff had a good understanding of the Mental Capacity Act 2005 (MCA) and the associated Deprivation of Liberty Safeguards (DoLS). They demonstrated their understanding of these principles in the way they cared for people. Staff believed that everyone at the service had the right to make their own decisions and respected them. The manager knew the process to follow if a person’s level of capacity changed so that the service would act in accordance with legal requirements.

There was a management structure in the service which provided clear lines of responsibility and accountability. Staff had a positive attitude and the management team provided strong leadership and led by example.

Relatives described the management of the service as open and approachable. They told us if they had any concerns, or comments about the service that they could approach the provider, manager or staff “without hesitation.”

People were asked for their views on the service regularly. There were effective quality assurance systems in place to make sure that any areas for improvement were identified and addressed.

Kingston House is part of Westlake Care who specialise in the care of adults who have a learning disability, autistic spectrum disorder, physical disability and/or a sensory impairment. Westlake Care have two other homes in the south west. Kingston House is registered to support a maximum of three people. At this inspection we found the service remained Good.

The service had a registered manager in place. 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.

Staff relationships were strained and there were sometimes arguments between members of the staff team. Staff told us the language and tone of these arguments could be quite aggressive. On occasion the arguments had taken place in front of people living at Kingston House. This demonstrated a lack of respect and a disregard for the potential impact on people’s well-being. The registered manager was aware of the situation and had informed the provider. A staff meeting had taken place to try and address the issues.

Roles and responsibilities were well-defined and understood by the staff team. The registered manager was supported by a deputy manager. There was a key worker system in place. Key workers are members of staff with responsibility for the care planning for a named individual.

Interactions between staff and people were friendly and supportive. There were enough staff available to help ensure people’s needs were met quickly. Staff spoke with people to inform them of what was happening when supporting them to move around the premises.

Recruitment practices helped ensure staff working in the home were fit and appropriate to work in the care sector. Procedures were not consistently followed and we have made a recommendation about this in the report.

Staff had received training in how to recognise and report abuse and information on how to report concerns within the organisation was on display. Staff told us they were aware how to raise concerns both inside and outside of the organisation.

People were assessed in line with the Deprivation of Liberty Safeguards (DoLS) as set out in the Mental Capacity Act 2005 (MCA). DoLS provide legal protection for vulnerable people who are, or may become deprived of their liberty. The MCA provides the legal framework to assess people’s capacity to make certain decisions, at a certain time. When people are assessed as not having the capacity to make a decision, a best interest decision is made involving people who know the person well and other professionals when appropriate. Records showed people were supported in line with the legislation. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

Staff had access to regular training. Training to help staff meet people’s specific needs was available. Staff meetings were an opportunity to contribute to the development of the service and individuals.

People’s support plans included detailed information about their health needs. Care plan reviews were held regularly and information up-dated accordingly. People had access to a range of activities outside of the service and were supported to access the local community on a regular basis.

There were quality assurance systems in place to monitor the standards of the care provided. Audits into various areas of the service took place monthly.

We saw within records and through discussion with staff and relatives that people's rights and ability to consent had been considered when planning and providing care and support. Records confirmed that the correct procedures were followed to protect people's rights when they were unable to consent to decisions being made about them.

The support plans we looked at provided staff with clear and up to date information about people's needs and how they should be met. People were supported to partake in a range of age appropriate activities.

Systems were in place, which ensured that people were protected from the risks of abuse. A relative we spoke to said 'I am able to visit the home at any time, the care is brilliant and I have never had cause to be concerned'

We found that the records held in the home about people using the service were mainly well maintained and up to date.

A system was in place to regularly assess and monitor the quality of the service being provided. We saw that the home liaised regularly with relatives and other agencies and responded promptly and appropriately to any issues or concerns raised.