Kingsthorpe View Care Home

Kingsthorpe View is a care home providing personal and nursing care for to up to 50 people. The service provides support to people living with a mental health diagnoses, dementia, physical disability or sensory impairment. The service accommodated 34 people at the time of our inspection in one adapted building, set out over two floors.

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

People living in the service were not safe and were placed at risk of harm. The environment, poor infection control processes, medicines management and lack of review of incidents at the service put people at risk.

The provider did not have effective quality assurance systems and processes in place to ensure improvements were identified where these were required at the service. The provider had failed to embed the improvements required from our last inspection

Staff had not received training in all areas relevant to people's health needs. People were left at risk of being supported by staff without the skills and knowledge to support their identified needs.

People’s oral medicines not given covertly were administered and disposed of safely. Staff involved in handling medicines had received training and recent competency checks around medicines.

Records relating to people's care contained information and guidance to enable staff to provide safe care and support for people. Risk management was in place for people who were at a high risk of falls and people who may present a risk to others from their behaviour. People's skin management and risk of falls or choking was effectively managed by staff.

Relatives and people told us that staff were understanding, patient and kind, and they gave positive feedback about the improving culture of the service and the management team.

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 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 Inadequate (published 11 January 2023) and there were breaches of regulation in relation to people's safe care and treatment, staff being deployed to safely meet people's needs, safeguarding, person-centred care, consent to care and how well the service assesses and manages risks and improves the quality and safety of care.

The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found the provider remained in breach of regulations in relation to the assessment and management of risk, governance and the quality and safety of care.

Why we inspected

We carried out an unannounced inspection of this service on 6 and 7 June 2023. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve; safe care and treatment, staff being deployed to safely meet people's needs, safeguarding, person-centred care, consent to care and how well the service assesses and manages risks and improves the quality and safety of care.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements, including warning notices in Regulations 11 (Need for Consent), Regulation 12 (Safe Care and Treatment), Regulation 17 (Good Governance) and Regulation 18 (Staffing). This report only covers our findings in relation to the Key Questions Safe, Responsive and Well-led which contain those requirements.

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 and Recommendations

We have found evidence that the provider needs to make improvements. Please see the Safe, Responsive and Well-Led sections of this report. The provider sent us evidence to show what action they had taken to the concerns we raised with them as part of this inspection. You can see what action we have asked the provider to take at the end of this full report.

We have identified breaches in relation to governance, assessment and management of risk and the quality and safety of care at this inspection. Please see the Safe and Well Led sections of this report.

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 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.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Kingsthorpe View Care Home on our website at www.cqc.org.uk.

Special Measures

This service has been in Special Measures since 11 January 2023. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

The inspection was prompted in part by notification of an incident following which a person using the service died. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of risk of falls. This inspection examined those risks.

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

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 Inadequate to Requires Improvement based on the findings of this inspection.

Kingsthorpe View is a care home providing personal and nursing care for to up to 50 people. The service provides support to people living with a mental health diagnoses, dementia, physical disability or sensory impairment. The service accommodated 30 people at the time of our inspection in one adapted building, set out over two floors.

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

People living in the service were not safe and were placed at risk of harm. The environment, poor infection control processes, medication management and lack of consideration of fire safety measures at the service put people at risk.

The leadership, management and governance arrangements did not provide assurance the service was well-led, that people were safe, and their care and support needs could be met. The provider had not ensured that their systems and processes were effective in enabling staff to provide safe and effective care for people. Lessons were not learned, and improvements were not made when things went wrong.

Records relating to people's care did not always contain information and guidance to enable staff to provide the safe care and support people required. Risk management was not in place for some people who were at a high risk of falls and people who may present a risk to others from their behaviour.

Medicines were not managed and administered safely. People’s skin management and risk of falls or choking was not effectively managed.

Not all staff received training in areas relevant to people's healthcare needs and completed an induction when they started work at the service. People were left at risk of being supported by insufficient numbers of staff without the skills and knowledge to support their identified needs.

We received mixed feedback from both people and their relatives regarding their opinions of the quality of the care and support they received. We observed positive interactions between staff and people using the service during the inspection.

Relatives and people told us that staff were kind, caring and they liked the staff who supported them.

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.

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 the service under the previous provider was Requires Improvement, published on 12 January 2022.

Why we inspected

The inspection was prompted in part due to concerns received about poor management of people's end of life care needs, safeguarding, consent, tissue viability and falls management. The decision was made for us to inspect and examine those risks under safe, responsive and well led. We inspected and found there were concerns with multiple areas of the service, so we widened the scope of the inspection to become a comprehensive inspection which included the key questions of caring and effective.

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.

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

We have found evidence that the provider needs to make improvements. Please see the safe, effective, caring, responsive and well-led sections of this full report. The provider sent us evidence to show what action they had taken to the concerns we raised with them as part 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 Kingsthorpe View Care Home on our website at www.cqc.org.uk.

Enforcement and Recommendations

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 people's safe care and treatment, staff being deployed to safely meet people's needs, safeguarding, person-centred care, consent to care and how well the service assesses and manages risks and improves the quality and safety of care at this inspection.

Please see the action 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 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.

Special Measures:

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