Kingsthorpe View Care Home

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We assessed 7 quality statements in the well-led key question and found areas of concern. The scores for these areas have been combined with scores based on the rating from the last inspection, which was requires improvement. We identified two breaches of the legal regulations. There were not effective governance, management and accountability arrangements. The systems to manage current and future performance and risks to the quality of the service did not take a proportionate approach to managing risk that allowed new and innovative ideas to be tested within the service. Information was not used effectively to monitor and improve the quality of care. Staff understood their role and responsibilities. Data or notifications were consistently submitted to external organisations as required. There were arrangements for the availability, integrity and confidentiality of data, records and data management systems.

This service scored 36 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The registered manager told us they had a 4-year plan to make the required improvements to the service. These plans had not been shared with the staff team. Staff told us they were not aware of any plans in place to make improvements. This meant there was not an effective shared vision, strategy or culture that staff were aware of and understood. Staff did not feel listened to. They told us they were not asked for their ideas and did not feel there was a focus on improving.

There was no process or system in place to ensure the management team’s vision, values and strategy could be developed through planning and collaboration with staff and people living at Kingsthorpe View. We found there was not a clear strategy in place that all staff in all areas were aware of in order to have a good understanding of the provider’s vision, values and goals and clear information on how these would be achieved.

We received mixed feedback from staff. Most of the staff we spoke with did not feel the management team were capable, compassionate and inclusive leaders. Staff told us, “No the home is not well-led, decisions are not made together.” Another staff member told us, “I wouldn’t raise staffing levels as it’s a waste time as nothing will get done. Staff do not get asked, it’s all [the registered manager]’s ideas.”

The service was not well-led. We were not assured the management team were competent at identifying risks and concerns. Where some risks had been identified poor action was taken. For example, we found skin integrity assessments were poorly completed. The registered manager told us this had been identified and the clinical team had been told within their meeting. However, no improvement had taken place. 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 decision making regarding their everyday care needs. This meant people were at risk of boredom, inactivity and social isolation due to the lack of person-centred activity. The systems and processes to monitor quality and safety were ineffective, and ongoing issues with management of the service had impacted on the quality of care people received. The management team did not have a process in place where safety was a top priority that involved everyone, including staff, people and relatives. This meant there was not a culture of improving people’s experiences and outcomes. The feedback we received from staff, relatives and people demonstrated the management team did not always have a positive, compassionate, listening culture to promote trust and understanding with each other to allow learning and improvements.

We received mixed feedback regarding freedom to speak up. Some staff told us that they felt management were approachable. However, other staff raised concerns of not being able to speak up. Staff were not confident on the process of using whistleblowing processes if they felt concerns were not being responded to. A staff member told us, “I think a lot of people are afraid to speak up to the management because we are over spoken, cut short or given excuses. We have no system to allow you to speak up.”

There was not an effective process and system to allow staff to speak up freely and honestly. We found there was not a culture to empower staff, people or relatives to speak up and raise concerns. Most of the staff we spoke to did not want the management team to know they had spoken with us. This meant to provider did not have a culture were staff felt empowered to raise concerns without any worries. The provider had a whistleblowing policy, however not all staff were aware of this policy and who they would raise their concerns to if they felt management did not take appropriate action.

Staff generally felt they were treated equally. One staff member raised concerns regarding staff training and having to complete this in their own time and if not completed feeling "threatened" with unpaid suspension and felt this impacted their caring responsibilities outside of work. Staff did not feel empowered or confident that their concerns and ideas would result in positive change to shape the service to allow an inclusive organisation.

We found the management team did not have a proactive approach to engage and involve staff with a focus on hearing the voices of staff. Staff were treated the same and not discriminated against because of age or gender. Staff had been provided with equality and inclusion training.

Staff did not feel the home was well managed. They told us they felt there were systems but they felt the management team did not want to identify concerns to take action and drive up the required improvements. Staff felt when they had raised concerns they were not always appropriately addressed or investigated. Staff were repeatedly told there was enough staff without a comprehensive check or investigation of staffing levels. The registered manager told us they had management support from the provider, and they visited often to completed audits of the service.

There were no effective systems or processes in place to ensure compliance with the requirements of the regulations. Throughout our onsite assessment of Kingsthorpe Care Home, we identified significant shortfalls in the way the service was managed. We identified concerns related to the staffing, management of falls, poor management of skin integrity, health and safety of the premises and good governance. These concerns having been ongoing from previous inspections from the CQC. We were therefore not ensured there was effective management of the service. Management daily walk arounds were not effective because it had not identified high risk concerns that we had found during our assessment. 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. We found 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. There was no quality assurance system or process in place to obtain feedback from people living at the service, relatives, staff and professionals. This meant there was missed opportunities to obtain people’s feedback and take appropriate action. Relatives did not feel the registered manger listened to them. One relative told us, “I made complaints at the start, but we do not feel comfortable. They probably listen but nothing happens or changes. I’ve spoken to the staff who also told us they have raised things and not been listened to. So, if people who work for them are not listened to, we are not going to be.” Notifications to the CQC were sent when required and the local authority was made aware of incidents.

Most of the people told us they were not supported to access the community for social or wellbeing support. One person did access the community on their own as and when they wanted to because they did not require staff support.

Staff were not able to explain how staff were working in partnership or within the community. One staff member told us they have had three people abscond and felt it was because people want to do more within the community.

We received mixed feedback from partners, some told us management were trying to make the required improvements. A partner told us the service was more reactive to when things were raised and there was a need for action, rather than having good quality systems and processes that identified risks and concerns so they could be acted upon before partners found or raised concerns.

The management team did work with the local GP, pharmacy and local authority. However, there was no clear process or system for people to engage with the local community to meet people’s wishes, preferences and choices.

Staff told us they were not provided with opportunities to discuss learning, what was working well, and what could be improved at the service. Staff were not encouraged or supported to raise concerns. Most of the staff we spoke to did not feel confident that they would be treated with compassion and understanding and not blamed or treated negatively if they raised concerns or ideas of improvements. One staff member told us, “I feel like if I saw a problem I could say to [the manager], but that’s about it such as if something is broken, I would tell them. When you say about raising things for improvements, you could, but whether the improvement is made is debatable.”

There was no effective process for improving quality of care. We found systems were not effective to ensure compliance with regulations by assessing, monitoring and improving quality of service. The provider and management audits had not identified risks or concerns and were not robust enough to identify where improvements were needed. For example, people were placed at repeated risks of falls because no reasonable mitigations had been put into place. Where issues had been identified and fed-back to the management team, action was not always taken to ensure the safety and quality of the service. For example, feedback was given regarding topical medication not being stored correctly and being accessible and unsecured in people’s bedrooms. This increased the risk of harm to people if used or ingested. The provider told us they had taken action and mitigated this risk for all the people. However, health professionals completed a visit and continued to find poor safe storage and management of topical medication. This meant people were at risk of harm from repeated failures from incorrect medicines storage. People and relatives had not been provided with an opportunity to be part of any learning at Kingsthorpe View. For example, after an incident or accident people were not involved in reviewing what had happened and what action could be taken to mitigate or reduce repeated incidents from happening again. This meant lessons were not always learnt to continually improve people’s experiences and outcomes. We found that not enough improvements had been made since our last visit. This meant the provider had not learnt from our last visit to make the necessary improvements.