Background to this inspection
Updated
19 October 2021
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.
As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
Inspection team
The inspection was carried out by one inspector.
Service and service type
Kingsley Cottage is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
Notice of inspection
We gave the service 30 minutes notice of the inspection. This was because we needed to confirm the covid-19 status within the home and check what infection, prevention and control measures were in place.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We used all of this information to plan our inspection.
During the inspection
We spoke with one person who used the service and three relatives about their experience of care provided. We spoke with eight members of staff including the registered manager, the provider, deputy manager, senior care workers and care workers.
We reviewed a range of records. This included four people’s care records and multiple medication records. We looked at three staff files in relation to recruitment. A variety of records relating to the management of the service, including policies, procedures and audits were reviewed.
After the inspection
We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records. We spoke with one professional who regularly works with the service.
Updated
19 October 2021
About the service
Kingsley Cottage is a residential care home providing personal care for up to 17 people aged 65 and over. At the time of our inspection, there was 17 people living at the home, some of whom were living with dementia.
People’s experience of using this service and what we found
Audits and quality monitoring were in place, but the recording of actions taken was not always clear; for example, on the outcome of actions taken to reduce accidents and incidents.
People were administered their medicines as prescribed. People’s needs and risks were assessed with management plans in place to reduce the risk of harm. Staff knew people well including their likes, dislikes, risks to them and how to minimise them. There were enough staff to meet people’s needs safely. Staff were recruited safely to ensure they were safe to work with vulnerable people. Staff and visitors wore personal protective equipment (PPE) in line with government guidance to reduce the spread of infection within the home.
Relatives told us they were kept up to date and informed and felt their family member were safe and well cared for. Feedback was sought from people and relatives. Staff gave mixed views on whether they had regular supervision. The service worked well with other professionals to ensure people’s needs were met safely and efficiently.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was requires improvement (published 24 January 2020) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made and the provider was still in breach of regulations. The service remains rated requires improvement. This service has been rated requires improvement for five out of six inspections, with one being rated as inadequate.
Why we inspected
The inspection was prompted in part by notification of a specific incident. Following which a person using the service died. We are currently gathering and reviewing evidence in relation to this. As a result, this inspection did not examine the circumstances of the incident.
The information CQC received about the incident indicated concerns about the management of falls. This inspection examined those risks. We found no evidence during this inspection that people were at risk of harm from this concern. Please see the safe and well-led sections of this full report.
At the previous inspection on 29 November 2019. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment and good governance.
During this focused inspection we checked they had followed their action plan and confirmed if they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
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.
We have found evidence that the provider needs to make improvement. Please see the safe and well-led sections of this full report.
You can see what action we have asked the provider to take at the end of this full report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Kingsley Cottage on our website at www.cqc.org.uk.
Follow up
We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside and meet with the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.