The Care Quality Commission (CQC) has rated Kingswood Manor in Woolton in Liverpool, inadequate, and placed it in special measures to protect people following an inspection in October.
Kingswood Manor, run by Harbour Healthcare 1 Ltd, provides accommodation and nursing and personal care for up to 44 people, most of whom are living with dementia.
The inspection was prompted by safeguarding incidents reported to CQC by both the provider and the local authority which raised concerns about the safety of people's care and the management of the service.
Following the inspection, the overall rating for the home is inadequate, as well as the areas of safe, effective, responsive, and well-led. Caring is rated requires improvement. The service was previously rated good overall, and for being safe, effective, responsive, caring and well-led.
The service has been placed in special measures which means it will be kept under close review to make sure people are safe and, if CQC do not propose to cancel the provider's registration, there will be a re-inspection to check for significant improvements.
Karen Knapton, CQC deputy director of operations in the north, said:
"When we inspected Kingswood Manor, we found a home where leaders didn’t have a good understanding of the issues it faced which had resulted in a deterioration in the standard of care being provided since our last inspection. We found serious concerns regarding people’s needs not being met that leaders must urgently address to prevent people from being harmed.
"For a service that provided care to people living with dementia, there was little specialist consideration given to their needs. There were no picture aids or signage around the home to help people navigate and not get confused. There also weren’t any meaningful activities available to prevent social isolation and loneliness, and we saw people sat all day in the lounge or alone in their bedrooms.
“It was concerning to see that people’s physical health conditions weren’t being managed properly either. For example, people were given pain relief medication too close together or too far apart placing them at risk of overdose or not having their pain properly controlled.
“In addition, the home was often understaffed, especially at night, which put people at risk of not having their needs met.
"Immediately after the inspection, we told the provider to submit an urgent and immediate action plan for improvement. Liverpool City Council was also informed about our concerns to ensure people were safeguarded from potential harm. We also placed conditions on the provider's registration with a requirement to immediately improve aspects of people's care and treatment.
“We will continue to monitor the service closely to ensure the necessary improvements are made and keep people safe during this time. If improvements are not made by the time we next inspect, we will not hesitate to take further enforcement action.”
Inspectors found:
- The home environment was not adequately maintained or clean
- The provider wasn’t supporting people living at the service to minimise the spread of infection
- Staff weren’t always recruited in a robust way to ensure they were safe and suitable to work with vulnerable people
- Referrals to other healthcare professionals weren’t always made in a timely manner which placed people at risk of deterioration
- Information about people's nutritional needs and risk was sometimes unclear and contradictory
- People weren’t always supported to express their views and make decisions about their care.
However:
- Most people said the food was nice, and they got enough to eat at mealtimes
- Records showed staff had received supervision in their job role and an appraisal
- People's rooms were personalised with items of their choice.
The report will be published on CQC’s website in the next few days.