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Kingly House Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 25 September 2019

About the service:

Kingly House provides accommodation for up to 17 adults with acquired brain injuries and neurological conditions. The staff team includes occupational therapists, a speech and language therapist and a physiotherapist to assist people with their support and rehabilitation. There were 16 people using the service at the time of our visit.

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

People’s care and support needs may not always be met in a timely manner due to the high use of agency staff. This was because they didn’t know people well and were unable to provide them with the same care regular staff could. A number of people commented on how the inconsistent use of regular staff affected the quality of the service.

People felt well cared for and staff had a caring and compassionate approach to those they were supporting and people felt confident in raising their concerns and that they would be investigated.

People felt safe at Kingly House and staff protected them from avoidable harm. People received their medicines safely and were protected from the risk of infection.

Regular staff had the skills and experience to support people and staff were recruited safely and had good training to support their role.

People had comprehensive care plans in place however, documentation within them didn’t always correspond, providing inaccurate information to the reader. This compromised the support provided by agency staff. Risks to some people’s health were compromised by the lack of monitoring of their assessed risks.

Regular staff knew people’s health needs and ensured they received treatment from the necessary health professionals to keep them well.

People’s nutritional needs were met with food plentiful and well balanced. The environment was homely and plans to improve the décor and presentation of the service had begun.

Staff gained consent from people prior to delivering care. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People were provided with a comfortable and homely place to live. A refurbishment plan was in place to improve the environment for people.

The service was without a registered manager therefore the providers operations manager was acting as manager. The overall monitoring of the service was not robust, and some monitoring had not yet been put in place.

Staff meetings and meetings for the people using the service had been held, though records of these were not always available. The management team worked in partnership with others for the benefit of the people using the service.

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 outstanding (report published 2 August 2017).

Since this rating was awarded the provider has changed its legal entity. We have used the previous rating to inform our planning and decisions about the rating at this inspection.

Why we inspected:

The inspection was prompted in part due to concerns received around staffing levels and the overall management of the service. A decision was made for us to inspect and examine those risks.

We have found evidence that the provider needs to make improvements. Please see the safe, effective, responsive and well led section of this full report.

The overall rating for the service has changed from outstanding to requires improvement. This is based on the findings at this inspection.


We identified a breach of the Health and Social Care Act (Regulated Activities) Regulations 2014 relating to Staffing. Details of the action we have asked the provider to take can be found at the end of this report

Follow up:

We will continue to monitor information we receive about the service until we return to visit as per our re-i

Inspection areas


Requires improvement

Updated 25 September 2019

The service was not always safe.

Details are in our safe findings below.



Updated 25 September 2019

The service was effective.

Details are in our effective findings below.



Updated 25 September 2019

The service was caring.

Details are in our caring findings below.


Requires improvement

Updated 25 September 2019

The service was not always responsive.

Details are in our responsive findings below.


Requires improvement

Updated 25 September 2019

The service was not always well-led.

Details are in our well-led findings below