Kingswood Manor

Updated 7 February 2024

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 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 two inspectors, a member of the medicines team and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Kingswood Manor 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 with us. Kingswood Manor is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with CQC to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

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 professionals who work with the service. 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 used all of this information to plan our inspection.

During the inspection

We spoke with the registered manager, regional manager, deputy manager, a nurse, 2 chefs, a senior carer, 2 care assistants and a domestic member of staff. We spoke with 7 people who lived in the home and 7 relatives, about their experience of the care provided.

We reviewed a range of records. This included 5 people's care records and multiple medication records. We looked at 3 staff files in relation to safe recruitment and a variety of records relating to the management of the service.

After the inspection visit.

We continued to seek clarification from the provider to validate evidence. We continue to review evidence in relation to people’s care, and the management of the service. We also liaised with the Local Authority to share information about the service and our inspection.

We concluded the inspection on 19 October 2023.

Updated 7 February 2024

About the service

Kingswood Manor provides accommodation for up to 44 people who need help with nursing or personal care. At the time of the inspection 39 people lived in the home. Some of the people living in the home lived with dementia.

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

People’s needs and risks were not adequately assessed, monitored or appropriately supported in the delivery of care. Staff lacked clear information about people’s needs and risks and records showed they did not receive the support they needed to keep them safe and well.

Accident and incidents and safeguarding events were not accurately recorded or monitored. There was little evidence that any learning from these events was shared with the staff team to prevent similar incidences from occurring in the future.

Medication management was unsafe. People did not always receive their medicines as prescribed, or in a safe way, which meant people were placed at increased risk of pain or discomfort from the conditions these medicines were intended to treat.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests. People’s consent was not sought in line with the principles of the Mental Capacity Act 2005.

Infection control standards were poor. Parts of the home and its equipment were unclean, malodorous and in need of repair.

The home itself is not dementia friendly. There were no signs or pictorial aids to help people navigate around the home or dementia friendly devices to help them determine the date or time of the day. There was also a lack of any meaningful activities for people to participate in to prevent social isolation and loneliness.

Staff were not always recruited following the completion of satisfactory pre-employment checks. Some staff training was not up to date and the provider used a high number of agency staff to cover gaps in the rota.

People had mixed opinions about the staff team. Some said staff were lovely, whereas others told us some were, but others were not. Some people said that staff did not always listen to them or respect their wishes when providing care.

Staffing levels were not always safe. This impacted on the timeliness and effectiveness of people’s care. Some people told us that it was difficult to obtain staff support during the night when they needed it. It also meant the provider’s ability to keep people safe or to evacuate them to a place of safety during an emergency such as a fire was compromised.

Systems in place to monitor the quality and safety of the service were not effective and did not ensure risks to people’s health, safety and welfare were identified and managed. Managerial oversight by the manager and the provider was ineffective. This placed people at risk of avoidable harm.

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

Rating at last inspection and update

The last rating for this service was good (published 10 June 2023).

At this inspection, we found that the quality and safety of the service had significantly declined. Multiple breaches of the regulations were found, resulting in a rating of inadequate. At this inspection, breaches of regulations 9 (person centred care); 11 (Need for Consent); 12 (safe care and treatment); 17 (Good governance); 18 (Staffing) and regulation 19 (Fit and proper persons) of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, were found.

The overall rating for the service has changed from good to inadequate. This is based on the findings at this inspection.

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

Why we inspected

This inspection was prompted by a number of safeguarding incidents reported to us by both the provider and the Local Authority which raised concerns about the safety of people’s care and the management of the service. As a result, we undertook a comprehensive inspection of the service.

We also 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 have identified breaches in relation to the safety of people’s care and risk management, the management of medicines, environmental safety, infection control, the implementation of the mental capacity act, staffing levels, staff recruitment, staff training and the overall governance of the service.

Immediately after the inspection, we asked the provider to submit an urgent and immediate action plan for improvement. The Local Authority were also informed about our concerns to ensure people were safeguarded from potential harm.

We also placed conditions on the provider’s registration with a clear requirement to immediately improve aspects of people's care and treatment which continued to place them at risk.

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.

Follow up

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.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service has been placed in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions of their registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.