Archived: Kingsley Nursing Home

Updated 13 October 2016

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This unannounced inspection was carried out by two inspectors on 7 September 2016.

Before our inspection we received concerning information about the care people received whilst at the home. We reviewed all the information that we held about the service such as notifications, which are events which happened in the service that the provider is required to tell us about, and information that had been sent to us by other agencies. This included the local authority and the clinical commissioning group who commission services from the provider.

During the inspection we spoke with six people who used the service, three relatives, five members of staff including nursing staff and kitchen staff, the deputy manager, the acting manager and the registered provider. We reviewed the care records of six people who used the service and looked at everybody’s food, fluid and turn repositioning charts, and three staff files. We observed how care and support was delivered in communal areas, people’s rooms and at meal times.

We also asked to look at other information related to the running of and the quality of the service. This included accident and incident documentation, quality assurance systems, maintenance records, training information for care staff, and arrangements for managing complaints.

Updated 13 October 2016

This unannounced inspection took place on the 7 September 2016. Kingsley Nursing Home provides accommodation for up to 25 people who require nursing care. At the time of the inspection there were 21 people living at the home.

There was a registered manager in post, however, at the time of the inspection they had been suspended pending investigations by the provider and the Nursing and Midwifery Council (NMC). A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the service is run.

People’s medicines were not managed appropriately. We found that the provider was unaware that one person had received too much of one medicine on two separate occasions within the previous two weeks. Staff did not always record when they had administered people’s medicines.

Poor standards of care had not been identified, or recognised as safeguarding concerns and as a result safeguarding notifications had not been completed to the appropriate authorities. This included the inappropriate use of bed rails, insufficient hydration and nutritional support, inappropriate care and support for people with diabetes, insufficient support to manage people’s general health and wellbeing, medicine errors, inadequate care plans and neglect by a member of staff to follow medical advice following a serious fall. As a result the Commission raised six safeguarding alerts following our visit to the home.

People were not protected from unsafe care as their risk assessments were incomplete and were not regularly reviewed or updated. The safety of the home environment was not maintained and we identified a number of areas that caused concerns regarding safe fire procedures which we referred to the local fire service and they identified a number of breaches of the fire regulations.

People did not have enough to eat and drink to maintain their body weight, health or well-being. We had serious concerns about the oversight of people’s nutritional care which led to most people losing weight and becoming dehydrated. There was a lack of nursing oversight to identify when people required medical care or referral to other health professionals. We told the provider to take urgent action for five people who were particularly frail. People were not provided with adequate support to eat their meals, or drink adequate fluids.

People had not been adequately assessed regarding their mental capacity to make their decisions about the care they received. Generic mental capacity assessments had been made for everybody which were not tailored about the decisions people may be able to make for themselves, or what could be in their best interests. Generic Deprivation of Liberty Safeguard (DoLS) had been made however they did not specify that people were being cared for in a recliner chair, or that bedrails were in place which could act as a form of restraint. We raised concerns about this and requested the home urgently review the suitability of these measures, and if appropriate to make urgent DoLS applications.

People’s healthcare needs were not adequately met. It appeared that nursing staff took people’s clinical observations such as blood pressure and pulse, however when results significantly changed and there were indications that people’s health had deteriorated, no action was taken to highlight this to the GP. When people had seen the GP, their advice was not adequately documented and there was insufficient evidence to show staff had followed this advice. In addition, staff had inadequate systems to manage the wound’s people had and the care they received.

Staff that were in senior positions did not have the knowledge, competence or ability to provide staff with adequate direction to ensure everyone’s needs were met. Members of care staff did not have the appropriate skills to support people to have all of their care needs met. There was a failure by staff to recognise that people did not have their care needs met.

People choices and preferences were not always respected. People with mobility difficulties asked to go into different areas of the home and this was not accommodated by staff, and they were left where they were, against their wishes.

People’s care plans showed that most people had not been involved with their care planning. Staff had a limited knowledge of people’s preferences or how they liked to spend their time.

Inappropriate assessments had been made about people’s needs before they moved into the home which failed to recognise that the service could not adequately meet their needs. This meant people were not always able to live at the home on a long term basis as expected.

People were not supported with their care and support needs in a consistent and person centred way. Not everyone had a care plan in place, and the care plans that were in place contained insufficient information and guidance to staff about how people liked to receive their care. Care plans were not adequately reviewed or updated when people’s needs changed.

People did not receive care that met their needs for pressure relieving support. Pressure mattresses were not set to the appropriate setting for each individual and people were not regularly supported to change their positions.

People were not supported to live a fulfilled life. Staff did not engage people in meaningful conversations or activities and people spent long periods of time without any significant interaction.

Inadequate systems were in place to identify and manage complaints. People were not supported to make complaints, and there was a failure to record and investigate people’s complaints.

There were inadequate arrangements for the day to day management and clinical leadership within the home. Standards of care had deteriorated and this had not been identified or actioned. Quality assurance systems were unsatisfactory and relied on members of the management team alerting the provider to changes of people’s needs or of significant events.

Records that were maintained within the home were not adequately reviewed. For example, people’s food and fluids charts were not reviewed, people’s repositioning charts were not reviewed, accidents and incidents were not reviewed and people’s care plans were not audited. This led to significant failures of care.

There have been seven breaches of the Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We have taken urgent action to place conditions on their registration that prevents any further admissions to the home and provide evidence that people are receiving safe care and treatment.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘Special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their 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. Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.