The Care Quality Commission (CQC) has rated Kingsthorpe View Care Home in Nottingham, inadequate and placed it in special measures following an inspection in November.
This was the first inspection of the service since the new provider took over in February 2022. The inspection was prompted in part due to concerns received regarding poor management of people's end of life care needs, safeguarding, consent and falls management. The inspection was only due to look at how safe, responsive and well-led the service was. However, as further concerns were found during the inspection, the areas of caring and effective were also looked at.
Kingsthorpe View, run by Kingsthorpe View Care Home Limited is a care home which provides personal and nursing care for to up to 50 people. The service provides support to people living with a mental health diagnoses, dementia, physical disability or sensory impairment. There were 30 people living at the service at the time of the inspection.
The home’s overall rating while under the previous provider was rated requires improvement. Following this inspection, the overall rating has dropped from requires improvement to inadequate. It has also dropped from requires improvement to inadequate for being safe. Effective and responsive remain rated requires improvement. Caring has dropped from good to requires improvement and well-led has remained inadequate.
The service is now in special measures which means it will be kept under review, by CQC and re-inspected to check sufficient improvements have been made.
Greg Rielly, CQC deputy director, Midlands network, said:
“When we inspected Kingsthorpe View Care Home, we found people weren’t always safeguarded from the risk of abuse. Also, the manager hadn’t investigated incidents to make sure abuse had been identified or taken measures to reduce the risk of people being exposed to avoidable harm.
“Risk assessments weren’t always reviewed or updated. Some people had modified diets recommended by a speech and language therapist, however care plans, risk assessments and dietary notifications hadn’t been updated to include this information. This increased the risk of people being given the incorrect diet which could put them at risk of choking.
“People lacked regular access to the outdoor space. The garden was unsuitable for people with mobility needs, and people couldn’t freely access it independently.
“As the service has been rated inadequate and placed in special measures. We will continue to monitor it closely to ensure people are safe. If we are not assured people are receiving safe care, we will not hesitate to take further action in line with our regulatory powers.”
Inspectors found:
- People living in the service were not safe and were placed at risk of harm. The environment, poor infection control processes, medication management and lack of consideration of fire safety measures at the service put people at risk
- The leadership, management and governance arrangements did not provide assurance the service was well-led, that people were safe, and their care and support needs could be met
- The provider had not ensured that their systems and processes were effective in enabling staff to provide safe and effective care for people. Lessons were not learned, and improvements were not made when things went wrong
- Records relating to people's care did not always contain information and guidance to enable staff to provide the safe care and support people required. Risk management was not in place for some people who were at a high risk of falls and people who may present a risk to others from their behaviour
- Medicines were not managed and administered safely. People's skin management and risk of falls or choking was not effectively managed
- Not all staff received training in areas relevant to people's healthcare needs and completed an induction when they started work at the service. People were left at risk of being supported by insufficient numbers of staff without the skills and knowledge to support their identified needs
- There was mixed feedback from both people and their relatives regarding their opinions of the quality of the care and support they received. We observed positive interactions between staff and people using the service during the inspection
- People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice
- The driveway up to the service was dark and overgrown which made it unsafe for staff and visitors.