Kingswood Mount

Updated 9 June 2022

Background

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 first day of the inspection was carried out by two inspectors and an expert by experience. The second day was carried out by one inspector.

Service and service type

Kingswood Mount 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.

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was no registered manager in post.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We gathered feedback from the local authority and other professionals who have visited the home since our last 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. We used all of this information to plan our inspection.

During the inspection

We spoke with one person who used the service and twelve family members about their experience of the care provided. We spoke with nine members of staff including the deputy manager, care, nursing and ancillary staff, area managers and other senior managers within the organisation.

We reviewed a range of records. This included five people's care records and four people's medication records. We looked at recruitment records for two staff members employed since the last inspection.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at quality assurance, training records, rotas, COVID-19 testing records and maintenance records.

Updated 9 June 2022

About the service

Kingswood Mount is a care home providing accommodation, personal and nursing care for up to 45 people; some of whom lived with dementia and physical disabilities. At the time of our inspection 36 people were living at the service.

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

The home's environment was unclean and unsafe. Infection prevention and control practices were inadequate and did not protect people from the risk of infections.

Relatives told us that staff members had a kind and caring approach towards their family members; but described the staff team as overstretched and under stress.

Records used to monitor, and review people's care were not fully completed and kept up to date. We found many examples where sections of care records were incomplete and where people's care plans had not been updated to reflect changes in their needs.

There were systematic and widespread failings in the way the service was led and managed. The systems in place for monitoring the quality and safety of the service were not used effectively. They failed to identify and mitigate risk and bring about improvements to the service people received. Daily checks of the environment, aspects of people's care and staffing had not taken place as required.

Medicines were administered safely and there were enough staff who knew people well to provide support.

People were supported to access healthcare services, staff recognised changes in people's health, and sought professional advice appropriately. Staff were confident about how to raise concerns to safeguard people.

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

Rating at last inspection

The last rating for this service was good (published 08 February 2019)

Why we inspected

The inspection was prompted in part due to concerns received about the safe care and treatment of people. 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 and well-led only. Please see full details in the individual sections of this full report.

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.

Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from good to requires improvement. 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

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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to safe care and treatment, infection prevention and control 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 request an action plan for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.