Archived: Kingsleigh Residential

Updated 13 April 2023

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 conducted by two inspectors and two Experts 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

Kingsleigh Residential is a ‘care home’. People in care homes receive accommodation and personal care as a single package under one contractual agreement dependent on their registration with us. Kingsleigh Residential is a care home without 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 the Care Quality Commission 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. 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 this information to plan our inspection.

During the inspection

We spoke with 10 staff members which included the registered manager and nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We spoke with 8 people that use the service, 11 relatives and 1 health and social care professional. We reviewed 8 people's care records and 8 medicine records. We looked at 6 staff files in relation to recruitment. A variety of records relating to the management of the service, including policies, procedures and audits were reviewed.

Updated 13 April 2023

About the service

Kingsleigh Residential is a residential care home providing personal care for up to 23 people. The service provides support to older people. At the time of our inspection there were 17 people using the service.

Kingsleigh Residential is a large detached property. There is a communal lounge and dining area on the ground floor. Bedrooms are on the ground and first floor. There is an enclosed garden at the front.

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

The provider and registered manager had not ensured people received safe or good quality care as there was widespread and significant failings across all aspects of the service. There was a lack of oversight and governance. This put people's safety at risk and meant people did not receive a caring service.

Improvements had been made to the environment and in relation to health and safety. However, previous shortfalls continued not to be addressed and further shortfalls were identified.

The provider and registered manager had failed to follow safe recruitment procedures and ensure staffing met people’s needs. Risk management was not effective to ensure risks to people were identified and reduced. For example, with catheter care, food and fluids and skin integrity. Medicines were not safely managed. People were not safeguarded from potential abuse and neglect and the reoccurrence of accidents and incidents.

Staff did not receive the necessary training or supervision to enable them to be fully skilled and knowledgeable in their roles.

The service was not well-led or managed. Records were poorly maintained. There was a lack of opportunities for people, staff and relatives to engage, feedback and develop the service. The provider had failed to adhere to the conditions on their registration.

Consent to care was not always delivered in line with guidance. 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; the policies and systems in the service did not support this practice.

Complaints and concerns were not identified or thoroughly investigated to ensure changes were made.

People enjoyed the food on offer. We observed staff being kind and caring with people. Consistent staff knew people well and their preferences.

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 02 September 2022).

At the last inspection in June 2022 we identified continued breaches of Regulation 12 (Safe Care and Treatment), Regulation 15 (Premises and Equipment) and Regulation 17 (Good Governance). Following the last inspection in June 2022, we imposed a condition on the providers registration in relation to Regulation 12 and 17.

The provider completed an action plan after the last inspection in relation to Regulation 15 to show what they would do and by when to improve. At this inspection we found the provider had made improvements in this area and was no longer in breach of regulation 15.

However, at this inspection we found the provider remained in breach of regulations 12 and 17. Additional breaches of regulation were also identified.

At our last inspection we made 2 recommendations in relation to medicines and the application of the Mental Capacity Act 2005. At this inspection we found the provider had not ensured these recommendations were met.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection and due to concerns identified in the management of safeguarding.

The overall rating for the service has changed from requires improvement to inadequate based on the findings of this inspection.

You can see what action we have asked the provider to take at the end of this full report.

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

Enforcement and Recommendations

We have identified breaches in relation to Regulation 7 (Requirements Relating to Registered Managers), Regulation 11 (Need for consent), Regulation 12 (Safe Care and Treatment), Regulation 13 (Safeguarding Service Users from abuse and improper treatment), Regulation 16 (Receiving and acting on complaints), Regulation 17 (Good Governance), Regulation 18 (Staffing), Regulation 19 (Fit and proper persons employed) and Regulation 20 (Duty of Candour).

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

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 follow our enforcement procedures.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service remains 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 the 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.