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Archived: Kingsacre Care Home Requires improvement

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Inspection Summary

Overall summary & rating

Requires improvement

Updated 6 May 2017

Kingsacre Care Home is a nursing and residential care home which provides nursing and personal care to adults. The home is registered to accommodate a maximum of 34 people. On the day of this inspection 29 people were living at the home.

We carried out this unannounced inspection of Kingsacre Care Home on 9 and 13 February 2017. The home was previously inspected in November 2014 when it was rated as good in all five key questions.

At the time of this inspection the home did not have a registered manager. A new manager had started working at the home in December 2016 and confirmed they had made an application to register with us. A registered manager is a person who has registered with the 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 and associated Regulations about how the service is run.

Since the previous inspection in November 2014 there had been changes to the management structure at the home and the home had been without a registered manager for some time. The systems previously in place to monitor the quality of the service and to ensure people received safe care were no longer being used effectively. While we found people’s personal care needs were being met and people were happy living at the home, we identified a number of areas that required improvement to ensure people received safe care and support The new manager had identified some of the concerns we found during this inspection.

Risks to people’s health and safety were not being managed and people were not being protected from the risk of avoidable harm. When we arrived at the home on the first day of the inspection we found many of the doors to people’s bedrooms and the communal areas, including the kitchen, were held open. Staff had used furniture and wooden wedges to hold these doors open. This meant that, should a fire break out, these doors would not close and therefore people would be placed at risk of smoke inhalation and the spread of fire would not be slowed by the doors. Also, when the furniture and wedges were removed, many of the doors would not have been effective in reducing the spread of smoke and fire as they did not fully close.

Records of the servicing of some equipment was either out of date or was not available. For example, the gas safety certificate was due to be renewed in May 2015 but this had not been undertaken. A number of other maintenance issues also required attention or review. The carpet in the lounge room required repair as the join had come apart and it posed a trip hazard. Some bedroom furniture was unstable and could be pulled over. The laundry room had peeling paintwork and debris on the floor which made this room difficult to keep clean. On the second day of the inspection we saw repair work being carried out to the doors and the provider gave assurances other action would be taken to ensure people’s safety. We also asked the manager to review the risks to people’s safety of uncovered radiators and the use of a portable ramp to assist one person from their room. Following the inspection the manager confirmed action had been taken to address the identified safety issues.

Staff recruitment practices were not safe. It was not possible from the information held in the staff files to ascertain whether checks had been completed properly and staff had been recruited safely. For example, where staff had gaps in their employment history, this had not been explored and one member of staff’s references were unsigned and undated. However, disclosure and barring (police) checks (DBS) had been undertaken.

Care plans were insufficiently detailed to describe people’s care needs. Staff were not guided about how to manage risks to people’s health and well-being and how to support people to meet their needs in their preferred manner. Where people had been identified as at risk of no

Inspection areas


Requires improvement

Updated 6 May 2017

The home was not always safe.

People were not protected from risks associated with the environment and unsafe practice.

Risk management plans were insufficiently detailed to ensure staff were guided about how to mitigate risks to people�s health and well-being.

Recruitment practices did not ensure that staff were safely recruited and were suitable to work at the home.

Medicines were not being managed safely.

People we supported by sufficient numbers of staff to meet their needs.


Requires improvement

Updated 6 May 2017

The home was not always effective.

Restrictions to people�s liberty in place to keep them safe had not been lawfully authorised.

People�s consent to receive care was sought. However equipment to monitor people�s movements was being used without a record of their consent being sought.

People enjoyed the variety and quality of the food. Documentation to monitor people�s food and fluid intake was not being effectively used to ensure their needs were being met.

People were supported by staff who were knowledgeable and skilled to meet their needs.



Updated 6 May 2017

The home was caring.

People benefited from their close and respectful relationships with staff. Staff were kind and caring.

People contributed to decisions about their care, although these weren�t recorded.

People privacy and dignity was respected.

People were supported to maintain friendships and important relationships.


Requires improvement

Updated 6 May 2017

The home was not always responsive.

Care plans contained insufficient detailed to identify people�s care and support needs. Staff were not provided with clear information to enable them to meet people�s needs in a consistent and safe way.

The routines within the home were flexible and respected people�s preferences.

The home encouraged people�s feedback and used this to promote improvements. The home took complaints seriously and acted promptly to resolve these.

People benefitted from some activities of interest and social events planned by the home.


Requires improvement

Updated 6 May 2017

The home was not always well-led.

The home did not have a registered manager in post.

The provider did not have effective quality assurance or audit processes in place to identify where improvements were required or when action was necessary to ensure people�s safety.

People, relatives and staff benefitted from the manager�s accessibility and commitment to improving the home.

The manager sought people�s views and worked co-operatively with other agencies to promote change.