Archived: Kingswood Lodge Residential Care Home

Updated 4 November 2022

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 Care Act 2014.

Inspection team

The inspection was carried out by two inspectors and an expert 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

Kingswood Lodge Residential Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was unannounced.

What we did before 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. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all this information to plan our inspection.

During the inspection

We spoke with two people using the service and spent time with others in communal areas. We spoke with the provider, the registered manager, the deputy manager, and one care worker. Following our inspection visit we spoke with five relatives by telephone.

We reviewed a range of records. This included people’s care and medication records, staff records, and records relating to the management and governance of the service. Not all the records we requested were made available to us during or after the inspection.

We planned to return to the service for a second day to complete our inspection. However, before we had the opportunity to do this, the provider closed the service and the local authority assisted the people using it to move to different care homes.

After the inspection

We continued to seek clarification from the provider and registered manager to validate the evidence found. However, the information we requested was not sent to us.

Updated 4 November 2022

About the service

Kingswood Lodge Residential Care Home provides accommodation and personal care for up to 21 older people, some of whom are living with dementia. The accommodation is set over two floors. There were seven people using the service at the time of our inspection.

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

This was our third inspection where the provider and registered manager did not have effective systems or processes in place to assess the quality and safety of the service. The principles of good quality assurance were not understood and there was little or no evidence of learning and service improvement. Audits were incomplete or non-existent.

Care plans and risk assessments remained a concern. They did not always reflect people’s current care and support needs. They had not always been updated following accidents and incidents. The information in some of them was incorrect or missing. This put people at risk of unsafe care.

Some medicines were still stored unsafely. Medicines records were incomplete, and the quality of recording was poor. A person’s turning chart had not been fully completed and we could not be sure they had been repositioned as required.

The condition of the premises remained a concern. Although the provider had made some improvements, we found broken and stained tiles in a bathroom, water damage in a person’s bedroom, an unsafe, unsecured cupboard in another person’s bedroom, and other hazards and unhygienic areas throughout the premises.

Staff training was still an issue. The registered manager was unwilling or unable to share the staff training matrix with us so we could not be sure that staff had had the training they needed to provide safe, good quality care.

Some relatives thought the service was safe, but others had concerns about falls management, the quality of the care and support provided, and communication. A relative said, “Care plans are wrong and a mess. No activities. No trips out. Poor communication with management.”

During our inspection we asked the registered manager to provide us with records to demonstrate the service was running effectively. These were not sent to us. We intended to go back to the service to carry out further checks but the provider closed the service before we had the chance to do this.

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 (report published 17 June 2022). At this inspection we found the provider remained in breach of regulations.

The overall rating for the service has remained the same. This is based on the findings at this inspection.

Why we inspected

We carried out an unannounced focused inspection of this service on 15 March 2022. Breaches of legal requirements were found. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

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

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

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 have identified breaches in relation to the premises and equipment, safe care, staffing, and governance.

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

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