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Kingston Nursing Home Inadequate

Inspection Summary

Overall summary & rating


Updated 26 September 2020

About the service

Kingston Nursing Home is a care home registered to provide personal and nursing care for up to 47 people aged 65 and over, some of whom are living with dementia. During our visit there were 29 people living at the home.

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

People did not always receive safe care. Before and during this inspection we identified and reported safeguarding concerns. People’s medication was not always administered safely and we could not be sure all staff administering prescribed medication were competent to do so. Risks to people’s care were not always managed safely and staff’s knowledge was not robust. During this inspection, we could not be sure people would always be appropriately supported in the event of a fire. The environment was not always clean and free of odours. Staff were not recruited safely.

We identified concerns around staffing levels. People and relatives told us staff were kind but did not have time to be involved in activities. People told us they felt “bored.” This could be a risk to people’s mental health.

We found widespread shortfalls in the way the service was managed. There was a risk of people receiving inappropriate care. Records were not always accurate or complete. Some people's care plans lacked information about people's needs, which meant staff were not provided with clear guidance to support and care for people.

There was no registered manager but an interim manager was in post and a new home manager had recently been recruited. The nominated individual did not always have good oversight of the day to day running of the service.

Quality assurance processes were not effective in identifying and addressing all the issues found at this inspection and in driving improvements.

For more details, please see the full report which is on the CQC website at

Rating at last inspection

The last rating for this service was Good (published 4 October 2018).

Why we inspected

Before our inspection we received information of concern in relation to people losing weight and timely action not being taken; risks to people’s care not managed safely including management of medication; and environmental safety risks and governance. Before the inspection, we discussed concerns with the provider and completed an Emergency Support Framework assessment but were not sufficiently assured. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We found evidence during this inspection that people could be at risk of harm. We reported these concerns to the provider who took immediate action to make improvements and promote people's safety. We also informed the local authority, clinical commissioning group (CCG) and the local fire authority of our concerns. We found the actions taken by the provider had been effective in mitigating urgent risks, however further improvements were required. Please see the Safe and Well Led sections of this full report.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The rating for the service has changed from Good to Inadequate. This is based on the findings at this inspection.


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 will continue to monitor the service to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in rela

Inspection areas



Updated 26 September 2020

The service was not safe.

Details are in our safe findings below.



Updated 4 October 2018

The service has improved to Good.



Updated 4 October 2018

The service remains Good.



Updated 4 October 2018

The service remains Good.



Updated 26 September 2020

The service was not well-led.

Details are in our well-Led findings below.