Kingsthorpe View Care Home

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We assessed all 6 quality statements in the effective key question and found areas of concern. People’s needs and rights were not supported. People’s care and treatment were not effective due to their health, care, well-being, and communication needs not being assessed with them or relatives to ensure staff were provided with clear information and guidance. People’s care plans were not kept up to date and assessments had not been completed in a timely manner. Staff were not provided with clear guidance on people’s preferences to enable them to support people in a person-centred way. People were not aware of their rights around care and treatment. Staff had good knowledge of the mental capacity act, including capacity and consent.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and relatives told us that they were not involved with planning or assessing care needs. One relative told us “No, we have not been involved in any care planning or involved in any discussions. We had a little meeting when [person] moved first in. No meetings since and not been part of any care plans.” This meant people and relatives were not involved with ongoing assessments of needs. Therefore, we are not assured people’s individual needs had been appropriately assessed and their rights supported.

Not all staff were involved with assessing people’s needs. Staff told us that they did not have time to read care plans in order to keep up to date with people’s changing needs. The management team told us they were in the process of updating people’s care plans and were working towards a timescale for this to be completed.

The provider had not always robustly assessed whether they could meet the needs of people with higher support needs they had admitted into the care home setting. This placed people at risk of their needs not being met. Oversight processes failed to identify poor assessments for people. For example, wound assessments were not completed or updated when required to provide clear information and guidance to staff on how to best support people. This is a vital tool in identifying and/or managing pressure ulcers to ensure people are protected from unnecessary pain and harm. People and those important to them were not always involved in the planning of their care and support needs. Feedback demonstrated there was a lack of consistent involvement from people and/or their relatives with assessments and the care planning process. Assessments we reviewed showed it was only clinical staff involved with the writing of assessments.

We received mixed feedback regarding the quality of the food served at Kingsthorpe View. People’s comments included, “I am not keen on the food.” And “I don’t like the food I make my own food.” One person told us, “The food is good.” Relatives told us, “I have seen the food it’s very bland and a beige diet. Same food in the evening which is sandwiches. Really cheap food. I do not think there is a lot of nutrition. I don’t think they get many treats because when I bring them in, they all want them straight away.” Another relative told us, “My mum lives with dementia, and they [staff] give my mum tea. She doesn’t drink tea, and they give her it, she has always had black coffee with no milk.”

Staff told us the management team did not encourage staff to learn about new innovative approaches that could improve the way they delivered care. For example, one staff member told us the registered manager had planned for people to have a library. However, they felt the decision was made with no input from staff, relatives or people living at the service. The staff member told us that was the only idea, and no consideration had been made that most of the people living at the service are living with dementia and require sensory simulation such as a sensory room or something that would be more beneficial for people living with dementia. Another staff member told us the home had not been adapted or decorated to make it dementia-friendly. They told us, “No, better colour paints are needed for people with dementia, bedrooms do not look cosy and warm.” Staff understood how to work with external health and social care providers to provide support in the most effective way.

People’s nutrition and hydration needs were not always supported in line with current standards. We were not assured people had their nutrition and hydration needs met. During our onsite visit on both days, it was hot and on both of our visits we did not see people having adequate hydration. We observed people did not have cold drinks where people could help themselves to a drink. On the second day the registered manager told us the jugs were in the fridge, however, we observed people did not have a drink with them and people were reliant on staff asking them and staff having time to make individuals a drink. The registered manager told us that people’s fluids were recorded to show people had enough to drink. However, staff told us that the drinks trolley came out at set times and some staff told us they recorded the amount of drink given on fluids logs not the amount drank by people. Therefore, we were not assured the fluids log was always accurate. The management team did not plan and deliver people’s care and treatment with people. This included not speaking with people or their relatives to obtain what was important and what mattered to the person receiving care and support. For example, people’s views on the food and drinks available were not obtained.

People and relatives could not provide us with feedback regarding services working together because they did not know which other services or health teams were involved with their care.

Staff told us they worked really well as a team and spoke positively about their colleagues and the teamwork. The management team told us they worked well with their GP and pharmacy. The management team also told us they had made referrals to the NHS outreach team for support on people who required support with their mental health.

We have received concerns regarding the service being in and out of their performance improvement programme. The management team have worked with a range of partners. Partners told us they felt the management team engaged with them while providing support. However, partners did raise with us that the provider has had intensive support due to the lack of consistency of compliance to their contracts within the last 3 years. Care and support were not always delivered in line with good practice. A health partner told us the environment was not dementia-friendly and dark and the manager was trying to improve this. Staff had reported to them that the environment could be noisy and chaotic at times. This meant people who were living with dementia could be at risk of further distress or confusion. During their visits they found a lot of people walking around the home with no footwear.

We were not assured that the management team always worked effectively across teams and services. Staff were not provided with clear information to ensure people’s care was delivered as assessed. Care plans were planned to be updated but this meant that if people had to move in between services such as admission into hospital there was a risk of information being shared that was not correct or up-to-date.

People were not supported to live as healthy as possible. One person told us there was nothing to do and that they smoked cigarettes to give them something to do. People told us they wanted to see other health professionals such as a dentist or have their hearing checked but had not been provided with these opportunities.

Staff told us people were not offered any physical activities because there were not sufficient levels of staff to offer this. Staff told us people received emergency care if needed such as a doctor who would be contacted if someone was not well or felt ill.

The provider did not have effective processes to empower people or their relatives to be part of managing health, care and wellbeing needs. This meant staff were not provided with accurate information on people’s needs and preferences to ensure people were supported to live healthier lives. Risks to people health and wellbeing were not always fully assessed or mitigated. We found no process in place to promote good physical and mental wellbeing. People were left long periods of time sitting and having nothing to do. This meant people were at risk of isolation and impact on their mental wellbeing.

People were not always receiving good outcomes from their care. People did not experience safe, person-centred care. Systems were not in place to empower people and relatives to be involved in monitoring and improving outcomes for people by routinely reviewing people’s care needs with them. Relatives did not feel people received good outcomes from their care. One relative told us, “They need to work on improving it [the service] and I’m shocked. A few months ago, I was invited into a different care home and I was shocked at the difference in the environment. This care home I visited a little while ago had memory boxes and their own doors were personalised, so [people] knew it was their bedroom. It was friendly and smelled nice. Mum’s home stinks. I’m not proud my mum is in there, it’s not homely and it’s a basic place. Very basic.” Another relative told us, “I would want to move him, but I’m too scared to move him to unsettle him, and there wasn’t any other home who would take him.”

Staff told us they were not aware of any plans or systems in place to continuously improve people’s outcomes. The management team told us of their plans on what they wanted to do within the environment of the home but there were no clear and robust timescales for when these improvements would be made to improve people’s outcomes.

There was no process in place for people or relatives to discuss their care and review what was working well and what needed to improve. People were not empowered to share their goals and wishes so that they could be supported to achieve these to promote good outcomes for people. People and relatives provided us with clear feedback on improving outcomes. The lack of engagement with people and their relatives was a clear missed opportunity to obtain ideas on how outcomes could be improved.

Where people were deemed to lack capacity to make decisions the management team had not always followed the Mental Capacity Act. Relatives were not always involved in best interests’ decisions and processes. A relative told us, “No, we have not been involved in care planning or best interest decisions or in any discussion that are made. We had a little meeting when mum moved in. No meetings since and, not been part of any care plans.” People had not been involved in their care planning and risk assessments, therefore could not have consented to their care plans. We were not assured people were supported to understand their rights around consent and the care the provider offered.

Staff were able to explain they must seek consent before providing care. They told us they respected people’s wishes if they did not want to get out of bed. Staff did have a good understanding of the Mental Capacity Act. However, some staff could not explain which people had a Deprivation of Liberty Safeguards (DoLS) authorisation in place, and what having a DoLS in place really meant for people.

There was no system in place to ensure people and relatives understood the care being offered to allow informed decision-making and consent to care. People did not have family, friends or someone important to them to advocate for them and we were not assured advocates were offered to people where appropriate. The Mental Capacity Act 2005 (MCA) provides a legal framework for making decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take decisions, any made on their behalf must be in their best interests and as least restrictive as possible. We found the Mental Capacity Act was not always followed. We found where people lacked capacity to consent the best interests decision-making process had not always been followed. Relatives had not always been involved in the decision-making process. This meant people were at risk of having best interest decisions made without considering their wishes, beliefs and values. Some people would be at risk if they did not have continuous supervision and control. Where this was the case, we saw staff had applied the suitable Deprivation of Liberty Safeguards. These safeguards ensure people who cannot consent to their care arrangements in a care home or hospital are protected if those arrangements deprive them of their liberty.