Kingsthorpe View Care Home

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We assessed all 8 quality statements in the safe key question and found areas of concern. We identified two breaches of the legal regulations. People and those important to them were not supported to understand safeguarding and how to raise concerns when they or their loved one did not feel safe. Staff understood their duty to protect people from abuse and knew how and when to report any concerns they had to managers. Safety risks to people were not managed well. Managers had not always assessed and reviewed safety risks to people and made sure people, and those important to them, were involved in making decisions about how they wished to be supported to stay safe. There were not enough staff to support people with their needs. Managers did review staffing levels regularly, however failed to make sure there were always enough staff on duty to meet peoples needs safely. Staff received relevant training to meet the range of people’s needs at the service. Managers made sure recruitment checks were undertaken on all staff to ensure only those individuals that were deemed suitable and fit, would be employed to support people at the service.

This service scored 31 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was not always a positive culture of openness and safety in which concerns were listened to. All relatives we spoke to told us they did not always feel listened to and felt excuses were made by management. One relative told us, “I have tried to take things up with the manager but there are always excuses so I don’t bother anymore.” Another relative told us, “I do [speak up] now, I didn’t before but things have improved.”

Staff were not provided with the opportunity to reflect after incidents, to ensure learning and improvement could occur. Staff could not explain what learning had taken place from incidents. For example, one staff member said, “We record the incident and then pass it onto the senior or management, we don’t hear anything back about what they have learnt.”

Incidents and accidents were logged. However, we found no effective processes or culture of lessons learnt from safety incidents to improve care for people by reducing known risks or mitigating safety risks. There was a failure to analyse and consider learning from incidents to improve people’s experience of care. We found risks were not always dealt with willingly as an opportunity to put things right, learn and improve. Records demonstrated repeated re-occurring incidents, also incidents where people had come to harm and no meaningful learning had taken place. This meant people were at risk of continued risk of harm. Lessons learnt that were identified were not always meaningful or actioned. This placed people at the continued risk of harm, including from potentially avoidable incidents. For example, a person had multiple unwitnessed falls in the lounge and the lesson learnt stated staff to not leave communal lounges unsupervised. However, the management team failed to ensure there were sufficient staff to enable this safety measure. The person had another unwitnessed fall and the registered manager lessons learnt was repeated of staff to not leave communal lounges unsupervised. Therefore, we were not assured there was a meaningful learning culture to ensure people were protected from the risk of harm.

We received mixed feedback from people and relatives regarding health referrals and transitions. One person told us, “I haven’t seen the GP for ages, a long time ago. Not seen the dentist for a long time. I have not had any well woman checks.” Relatives told us that they were asked questions in relation to their loved one’s care needs when their loved one either first moved into the home or before.

Staff told us that when people were referred to the care home the management team completed an assessment of their needs. The assessment was normally done with the person, relatives and if required, health professionals such as hospital staff.

A health professional who was involved in a pathway of care for support regarding people’s mental health found records were not always completed adequately on people’s distressed or agitated behaviour and their mental health. Staff provided them with verbal explanations for the records, however, this sometimes contradicted what records were showing. This meant it was difficult for professionals to review people’s mental health and to provide clear strategies to enable joined-up care. A health professional told us that a referral for a reportable skin integrity wound had not been reported until they had asked the registered manager for it to be reported. This meant we were not assured people always received safe collaborative and joined-up care. The regiseted manager told us the wound was not reported due to the NHS guidance of, a person having to be admittied for 29 days before they can report a wound to the NHS team.

Care records were not reflective of people’s care and support needs. Care plans did not always include information and guidance regarding which professionals were involved or whether suitable referrals had been made. For example, one person was underweight and the care plan stated the person be weighed weekly. However, there was no information on whether a health referral was required to support the person. This meant people were at risk of further developing health conditions.

People were not always protected from avoidable harm and neglect. We found repeated incidents of falls with no review of how to mitigate or reduce the risk of falling again. Therefore, we were not assured that people were protected from harm. Some relatives did not feel their loved one was always safe. One relative told us, “The carers do their best; I do have concerns about night staff; they are agency staff. I have asked to have a camera put in my relative’s room with a sign on the door to make people aware but have been told I can’t.” Other relatives raised concerns of neglect. Relatives told us their loved ones were living with dementia and were not supported appropriately to maintain their personal hygiene. One relative told us, “When I visit, she always looks uncared for, her hair is dirty, nails are long with dirt, and teeth are disgusting.” Another relative told us, “My dad has been in a soiled pad a long time, it is not good care. My dad’s eyes get stuck and dribble on their chin. My dad is not kept clean.”

The management team were able to explain their safeguarding process. However, we were not assured that they fully understood their responsibilities regarding protecting people from the risk of harm and neglect. Records demonstrated poor safety management of repeated falls and risk management. There was not a strong understanding of how to always take appropriate actions to protect people from harm and neglect. Staff understood how to respond to allegations of abuse. Staff told us that they had no concerns, but if they did, they would report to the management team. However, staff were not confident on the process of using whistleblowing processes if they felt concerns was not being responded to.

We observed people were not always protected from harm and neglect. We observed a person to be soaked in urine. A family member had notified staff the person required support; however, we found hours later this support had not been provided. This meant the person was at risk of neglect and harm from being left in a soiled pad.

There was no process or system to ensure people and relatives were supported to understand what safeguarding means to them and how to raise concerns when they don’t feel safe, or when they have concerns about the safety of other people or if concerns were not dealt with who they could contact. We found there was not a culture committed to taking immediate action to keep people safe from harm and neglect. Systems to review and learn from accidents and incidents were not fully effective. Although falls incidents were reviewed by the management team each month, action was not always taken to reduce future risks. Records showed multiple people had sustained multiple unwitnessed falls, some resulting in injury. However, not enough action had been taken to prevent recurrence of unwitnessed falls. This placed people at risk of harm from injuries relating to unwitnessed falls. Records showed safeguarding referrals were made to the local authority safeguarding team if needed. However, incidents were not always investigated to find the root cause. This meant people were at continued risk of harm. If an allegation of abuse was made there were appropriate policies in place to guide the staff team. Staff had completed safeguarding training.

People or relatives where appropriate, were not involved in management plans regarding risks. People told us that they were not aware they were able to communicate their risk support needs to receive the right type of support. One person said, “I haven’t got a care plan, and I haven’t been told I’ve got one.”

The management team told us people or relatives had not been involved in care plans or risk assessments, but this was something they were planning to do. This meant people had not been involved to manage their risks or been empowered to make their own informed decisions regarding risk management. Skin integrity was poorly managed and records were poor. For example, the registered manager and deputy manager could not explain people’s skin integrity support needs. Some people required support with wound management. However, the management team and staff who were responsible for providing support could not explain or provide records that showed what stages the wounds were at, what care and support people required and whether referrals had been made to other health professionals to enable effective joined-up care.

We observed people, who required staff support when they became distressed to de-escalate, did not receive support in a timely way because there were not sufficient staff. A person had repeated incidents of distress and there were no staff present to intervene or support. They were repeatedly opening and closing a door and at risk of harm of the risk of trapping their fingers in between the door and frame. This meant people were at risk of further harm, emotional distress, anxiety and agitation due to insufficient staff to respond. We observed communal areas of the home were left unsupervised with people who were at known risk of harm from falling. For example, one person had an unwitnessed fall in June which had resulted in a head injury and a hospital admission. The inspection team observed this person to be left unsupervised and walking unsteadily. This meant the person was not protected from the known risk of harm.

The provider did not have effective systems in place to ensure staff were provided with reflective guidance on how to support people with risks. Care plans we reviewed demonstrated people or their relatives were not involved in that process. We found serious shortfalls in the management of pressure area care and wound management which placed people at increased risk of harm. There were no detailed and accurate pressure area risk assessments in place for people at risk of pressure area damage. This placed the people at heightened risk of developing pressure damage because risk assessments had not indicated the level of risk and how to mitigate and manage the risks. The provider took action after our visit and updated the wound management plans. Risk care plans about people’s care were not person-centred. For example, people who were living with diabetes all had generic information in their plans. A clinical nurse was able to explain one person’s person-centred care needs, however, these were not recorded within their care plan to ensure all staff had the right information and guidance to follow to on how to support people with their glucose levels. The provider told us they took action after our visit and updated peoples’ diabetes care plans. However, health professionals visited after our onsite assessment and continued to find missing information regarding what type of diabetes people had been diagnosed with.

Relatives felt the environment was not managed safely. Relatives told us they had raised their concerns to the registered manager regarding the garden area being a risk to people due to the surfaces being uneven and not being a nice environment for people. However, no action had been taken to resolve the risks and concerns. Relatives felt this restricted their loved ones from getting fresh air and having the choice to sit outside. People were not always cared for in safe environments and we found broken furniture that could cause people harm. Some people’s bedrooms were dark due to overgrown trees. The management told us that they took immediate action and the furniture we identified had been fixed. However, 10 days later health professionals completed an unannounced visit and found further evidence of broken furniture. We found a person was not provided with a call bell who was cared for in bed. This meant they could not request staff support if needed. The provider told us the day after our visit they had taken action and the person had been provided with a call bell.

The management team described a process for monitoring the safety of the environment. The registered manager told us they completed a manager walk around and checked the building during this check. However, we were not assured these checks were effective for the building because we saw areas of the home that were a risk which had not been identified by these checks in order to keep people safe. Staff knew how to respond in the event of an emergency evacuation. For example, if a fire alarm sounded, staff could explain how people would be supported to move into a safe space.

We observed the home was not always safe in the event of needing to evacuate the care home. A fire exit was not clear of blockages. We found a table, chair, wood with nails, and a fire extinguisher on the ramp meaning this would not allow people and staff to safely exit the building. We also found fire doors were wedged open. This meant people were at risk of harm from fire due to poor implementation of fire prevention practices. The management told us that they had taken action to mitigate our concerns and risks. However, 10 days later health professionals completed an unannounced visit and found further evidence of blocked fire exits.

The environment was not always kept safe. A legionella check was completed in June 2024 and identified risk actions to be completed. These actions remained outstanding. This meant there was a risk of water-borne bacteria like legionella that could cause people harm. The registered manager told us they had a meeting with contractors however there were no assurances any action was taken to mitigate the identified risks. Other safety checks had been completed such as fire alarm and gas safety checks to prevent harm to people. We found people were at risk of accessing risk items such as razors and air fresheners, without staff supervision. This was of particular risk for those people living with dementia who were reliant on staff to maintain their safety. The home was not designed to meet people’s needs. The home was not dementia-friendly. This meant people were at risk of further distress due to the environment they were living in.

Relatives expressed their concerns regarding the number of staff. One relative told us, “I do not think one staff member where my mum is makes her safe, especially in an emergency. Also, mum does not look well-kept, does not have as many showers, hair washes, nails cleaned, or teeth cleaned.” This meant people were at risk of harm and neglect. Another relative told us, “There are too few staff. It must be a hellhole for the residents with people screaming. There are people wandering around. When I arrived my relative was hanging their legs over the sides of their bed.” Relatives told us staff were well trained and tried their best. One relative told us, “The staff are phenomenal but very unappreciated by the provider and ‘very much let’s run it with the least amount money, staff don’t even have time to have a chat with the residents.”

All the staff we spoke to told us there were not sufficient staffing levels. Staff told us, “Definitely not enough staff, we do not even get time to sit and talk with them [people living at Kingsthorpe View]. We are rushed trying to make sure the basic care is completed. We do not have enough staff to supervise communal areas especially at busy times.” Another staff member said, “Not enough staff, residents have to wait a lot for staff to be available, when we go on our breaks, we are then rushing to catch up on the tasks that need to be done, our phones start showing which tasks need to be completed so we rush to get them completed, we don’t have time to do anything else.” Another staff member said, “No one gets person-centred care because we do not have enough staff, we do try our best with what we have and do feel guilty.” Staff did not always have appraisals and regular supervision was not in place to support staff development in their roles. The registered manager shared a record to show staff had an appraisal and regular supervisions. However, this did not match staff feedback. Staff told us, “Staff meetings are every 3 months but a lot of the time they get cancelled. No one-to-ones and I don’t know about appraisal.” Another staff member told us, “Senior care staff and nurses have meetings and I think we have a supervision every six to eight months.” The registered manager told us they disputed that staffing levels were insufficient to keep people safe and provide good quality care in line with the regulations. They also told us only one staff meeting had been cancelled and that all staff had recieved an apperaisal.

We saw there were not enough staff to provide support to people safely. Staff were not deployed effectively around the building to provide timely support to people. We observed communal lounges left unsupervised leaving people at risk of harm. We observed people who required staff support when they became distressed did not receive support in a timely way because there were not sufficient staff. One person had repeated incidents of distress and there were no staff present to intervene or support. On two occasions the inspection team had to intervene because the person was at risk of harm by walking with a purpose, distressed and repeatedly trying to shut the lounge door with the risk of their fingers getting trapped between the door and frame. This meant people were at risk of harm. We saw staff were suitably trained to complete their roles. When staff had time, they used their training to respond effectively to people’s needs.

The management team failed to ensure that there were sufficient number of staff to ensure people’s needs were met. This meant people did not routinely have access to key elements of care, including meaningful leisure time, emotional support, adequate supervision to keep them safe and adequate personal care. Rotas showed inadequate staffing levels to ensure people’s needs were safely met. One part of the care home had 10 people and only 1 care staff member to provide care. The registered manager told the inspection team this was staffed with 1 staff member because all 10 people were high-functioning, low-level dependency and more independent. However, their dependency tool scoring record, (this is a record to show the level of care that a person is required to determine staffing levels) demonstrated only 1 person out of the 10 was low-level dependency. There was not a clear process to ensure there were enough staff. The registered manager had used a calculation tool to assess how many staff were needed to meet people’s needs. The tool was used as a whole service and no consideration for each floor and each person's needs on each floor or a consideration to the layout out of the service. This meant the tool used was not effective. Safe recruitment processes were followed. For example, previous employers were contacted to give references on the staff member. Staff also had regular Disclosure and Barring Service (DBS) checks. These check the police database for convictions or warnings that may impact the staff members safety to work with people. The service employed some nurses. These nurses were registered with the regulatory body (the nursing and midwifery council). The management team completed regular checks to ensure their nursing registration was maintained.

Relatives told us that the home was not always kept clean. One relative told us, “I think it comes down to staffing levels and not having the time to do the cleaning, also the way some staff work. Residents will wet themselves on the lounge chair and some staff will clean it up, other staff will leave it because they are busy.” This meant people were not protected from the risk of infection.

Staff told us the home was not always clean and they could not always follow infection prevention and control guidelines because there were not enough staff or time. One staff member told us, “No, the home is not clean to what it should be, the cleaners do the best, but it is not what it should be. Cleaners finish at 3pm and then [management] expect staff to continue with the cleaning, but staff have not got the time, so things do not get done.”

The home was not clean and hygienic. We observed a kitchen within one unit of the home to have visible dirt marks and the fridge had dried stains. The communal bathroom was dirty, dusty and had dried liquid marks in the bath and sink where clean towels were stored. We observed the home was in a state of disrepair meaning it could not be cleaned effectively. Paint was found to be peeling off walls and there were chipped skirting boards and chipped pain on doors. We saw that staff and people did not always have access to hand soap or towels. We found one area of the home did not have any soap or towels in the toilet and no paper towels in the kitchen area. This meant hand cleaning could not take place in a hygienic way.

There were policies in place to guide good infection control practices. However, from our observations and feedback, we found these were not always followed to ensure cleanliness was maintained. Staff had completed infection prevention control training.

Where people were deemed to lack capacity, some relatives told us that they were not involved with reviews of their loved one’s medicines. One relative told us, “We do not get told about anything medical. We turned up and were not told [our relative] had a fall until we got there.” A person told us they did not know what medicines they were taking but staff did support them. “I don’t what the tablets are. If I need anything the staff get it for me.” People or relatives did not raise any concerns regarding medicine management. One relative told us, “I think my dad gets all his medication.”

Staff were able to explain how they supported people to take their medicines safely. Staff knew who to report medicine concerns too. Staff told us they would report this to the management and contact a doctor.

Medicines were not always managed safely. We found medicines were not always stored in a locked area, to prevent people accessing them unsafely. People were at risk of accessing items such as prescribed topical creams and drinking thickening powder and supplements without staff supervision. This was of particular risk for those people living with dementia who were reliant on staff to maintain their safety. The registered manager told us that they would ensure all supplements would be stored securely, however, we checked at the end of our visit and found they were still stored unsafely. After our visit the provider told us they had taken action and had removed the risk of topical creams being accessed. However, health professionals completed a visit 10 days after our visit and found further risks with medicines management. The found out-of-date creams or wrong names on creams found in other people’s bedrooms. The health professionals also told us they found medicines were not stored at the correct temperature. This placed people at continued risk of harm. Staff kept clear records of when they had given prescribed medicines. We saw medicines were given as prescribed. Staff had received training on how to administer medicines safely. The management team had regularly assessed the staff’s competency, to ensure they were following best practice.