Kingland House Residential Home

Kingland House is a care home for up to 44 older people, some of whom may be living with dementia. The home was originally four private houses which have been adapted and linked together. There were 36 people living in the home at the time of our inspection.

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

People told us they felt safe living at Kingland House, and that staff were caring and supportive.

Risks to people were assessed and regularly reviewed. Staff understood the actions needed to minimise the risk of avoidable harm including the prevention of avoidable infections.

Staff had completed safeguarding training and understood their role in identifying and reporting any concerns of potential abuse or poor practice.

Medicines were administered safely by trained staff who had their competence checked regularly.

There were enough trained, experienced staff to meet people’s needs. Safe recruitment practices were in place: appropriate checks were completed to ensure only suitable staff were employed. Staff received induction, on-going training and support that enabled them to carry out their roles safely and effectively.

People spoke positively about the food. We observed home cooked, well balanced meals being served to people and a range of drinks being offered.

People received care that was responsive to their individual needs. Staff understood how people preferred their care and support provided. Care plans were person-centred and reflected both care needs and lifestyle choices.

People had access to healthcare services and were involved in decisions about their care. Partnerships with other agencies and health professionals enabled effective outcomes for people.

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.

The culture of the service was positive and open. Governance systems and oversight of the service had been reviewed and improved. Issues were identified, and actions taken to address any shortfalls. Staff spoke positively about their own roles and teamwork.

Rating at last inspection (and update)

The last rating for this service was requires improvement (published 25 July 2019) and there was a breach in one 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 we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We undertook this targeted inspection to monitor the service.

We inspected and found that improvements had been made and the rating of requires improvement was no longer reflective of the service. We widened the scope of the inspection to become a focused inspection which included the key questions of safe, effective and well-led.

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

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Kingland House Residential Home is a ‘care home’ registered for 44 people. There were 32 older people living in the home at the start of our inspection. People had a variety of care and support needs related to their physical and mental health.

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

Kingland House Residential Home provided a friendly, welcoming and relaxed environment for people and visitors.

People were supported by staff that were caring, compassionate and treated them with dignity and respect. Staff knew about people’s life history and understood their personal circumstances, preferences, interests and communication needs.

People received person centred care from staff who developed positive, meaningful relationships with them. People had opportunities to socialise, engage in activities and pursue their interests and hobbies. Care plans were detailed and reflected people's individual needs and preferences. People used the communal areas of the building and people’s experience of meal times had improved since our last inspection.

People and relatives said the service was safe. Staff demonstrated an awareness of each person's safety and how to minimise risks for them. They were supported by staff with the skills and knowledge to meet their needs. Staff had regular training and felt confident in their role.

Risks to the majority of people's health, safety and wellbeing were assessed. Risk management plans were put in place to make sure risks were reduced as much as possible whilst still promoting their independence. Where we identified shortfalls in risk management actions were taken immediately by the registered manager and staff team. Dark coloured sensor mats were used in the home. People with dementia can perceive these as holes in the ground and this can make their use restrictive. We have made a recommendation about reviewing this use in line with good practice.

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.

There was strong and committed leadership in the service and people, relatives and staff spoke highly of the registered manager. There was a positive culture at the service where staff felt listened to and supported. There was a drive to continuously improve the service for people and the registered manager and staff team were very responsive to any areas for improvement identified.

There was open culture that focused on learning lessons and finding different ways of making improvements for people. Since our last inspection they had kept the number of people living in the home at below capacity to allow improvements to be made.

The registered manager and provider had implemented quality assurance systems to assess, monitor and improve the quality and safety of the service provided. These were not fully embedded. There was a continued breach of regulation.

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 Inadequate (supplementary report published May 2019). There were multiple breaches of regulation. We served a Notice of Decision to add conditions to the provider’s registration requiring them to report on actions taken to improve the service.

This service has been in Special Measures since 25 January 2019. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

At this inspection enough improvement had not been made in relation to oversight and the provider was still in breach of one regulation.

You can see what action we have asked the provider to take at the end of this full report.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside 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.

Kingland House Nursing and Residential Home was registered for 44 people. There were 32 older people living in the home at the start of our inspection. A further three people who resided in the home were in hospital at this time. People had a variety of care and support needs related to their physical and mental health.

This unannounced inspection took place on 3, 6 and 7 December 2018.

The service did not have registered manager. The previous registered manager had ceased their employment with the service and deregistered in December 2107. A registered manager is a person who has registered with the Care Quality Commission 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. A new manager had been appointed and had started their employment six weeks before the inspection. They had put in an application to become registered with the CQC.

We carried out this inspection in response to information of concern we received alleging that people were not receiving safe care and that there were issues with the management and oversight of the service. During our inspection we gathered evidence that reflected these concerns.

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.

At this inspection, we found that the management of risk did not ensure people received safe care and treatment. Risks related to people’s mobility, nutrition and skin health were not being managed effectively. This was a breach of the regulations.

Notifications had not been made to the Care Quality Commission where required. This was a breach of the regulations.

Staff understood how to report abuse but we found two examples where allegations of abuse had not been responded to robustly and transparently. We also found that restraint was being used without an appropriate framework to ensure peoples' rights were protected and a Deprivation of Liberty Safeguard had not been applied for someone who was not free to leave the home and was indicating regularly they wished to leave. This was a breach of the regulations.

People were not always supported to make choices or to consent to their care within the framework of the Mental Capacity Act. This was a breach of regulation.

People told us the food was enjoyable. The meal time experience was variable for people: some people were not treated respectfully and care plans were not followed. We found other care plans were not followed. This was a breach of regulation.

The home had been through a period of unsettled leadership and change, the impact of which had not been adequately assessed or planned for.

Oversight and governance in the home had not been effective in identifying shortfalls and unsafe practices. This was a breach of regulation.

Care staff were kind throughout. People’s dignity and privacy was not always respected.

People had access to health care for acute and chronic health conditions. Referrals had not always been made when people’s needs indicated that this should have been sought. .

Some staff training was not up to date. This meant that staff may not have always had the skills to provide appropriate care and support. People told us they sometimes had to wait for staff and staffing levels impacted on people’s experience of care.

People knew how to raise concerns and were confident they would always be heard.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

A registered manager was in post at the time of the inspection. A registered manager is a person who has registered with the Care Quality Commission 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.

This inspection was unannounced and took place on 13 June 2017. At the last inspection in October 2016 the service was not meeting the requirements of the regulations and CQC took enforcement action, which included putting the service in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe.

During this inspection the service demonstrated to us that significant improvements have been made and is no longer rated as inadequate in any of the key questions. Therefore, this service is now out of Special Measures.

People's needs were assessed including areas of risk, and reviewed to ensure people's safety. We received positive written feedback from GP's and health professionals regarding the care and support provided to people.

Staff knew people well and treated them with dignity and respect. Wherever possible people and their relatives were involved in assessing and planning the care and support they needed.

People received their prescribed medicine when they needed it and appropriate arrangements were in place for the safe storage, management and disposal of medicines. Infection control processes were in place.

People were cared for, or supported by, sufficient numbers of suitably qualified and experienced staff. Robust recruitment and selection procedures ensured staff were recruited safely. Staff spoke positively about the induction, training and support they received.

The registered manager was aware of their responsibilities in regard to the Deprivation of Liberty Safeguards (DoLS). These safeguards aim to protect people living in care home and hospitals from being inappropriately deprived of their liberty.

People knew how to make a complaint and felt confident they would be listened to if they needed to raise concerns or queries.

There was a forward programme of quality assurance systems being introduced to monitor and improve the quality of the service provided.

A registered manager was in post at the time of the inspection. A registered manager is a person who has registered with the Care Quality Commission 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.

This inspection was unannounced and took place on 26 and 28 October and the 2 November 2016. At the last inspection in February 2016 the service was not meeting the requirements of the regulations and CQC took enforcement action.

At this inspection we identified serious shortfalls and both on-going and new breaches of the regulations. You can see some of the action we have asked the provider to take at the end of this report.

We identified that risk management and administration of medicines was not consistently safe. In addition, people were not protected from the risk of abuse because the systems in place did not safeguard them. The environment posed some risks to people and we made a recommendation that staffing levels were reviewed to ensure people’s needs were met in a person centred way.

Staff told us they were informally supported but records showed some staff had not received adequate training or supervisory support to ensure they were safe and competent in their role.

Some people told us staff were caring. Other people felt they had not received a caring service. We observed that people experienced care differently depending on the skills of the care worker supporting them.

People's needs had been assessed, and care plans reflected people’s needs in an individualised way.

The governance systems in place were not effective, as they did not assess and monitor the quality of the service, and did not fully assess or mitigate the risks to people.

We have imposed conditions of registration for the breaches of regulation 12, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The overall rating for this service is ‘Requires improvement’. However, we are placing the service in 'special measures'. We do this when services have been rated as 'Inadequate' in any key question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services 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

Kingland House Nursing & Residential Home is registered to provide accommodation for up to 44 people who require nursing or personal care. At the time of the inspection there were 41 people living at the home. There was a new registered manager in place. A registered manager is a person who has registered with the Care Quality Commission 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.

At the last inspection we found that people were not safely supported because the medicines management system was not safe. At this inspection we found that people were safely supported with their medicines.

At this inspection we found that people who were more independent were satisfied with the service they received. One person told us, “Everything is lovely”, and a family member said, “Staff have been very good and supportive”.

Staff were warm, friendly and caring towards people. Staff smiled with people and gave them time to say what they wanted to.

People’s consent was sought before staff assisted them and people were supported to access healthcare professionals when they needed to.

Complaints information was displayed and there was a consistent system for investigating, managing and responding to complaints.

We received positive feedback about the new manager in terms of the changes they had started to implement, and the support they provided to staff.

However, at this inspection we identified four new breaches of the regulations.

Risks to people’s safety were not consistently assessed and managed to minimise risks. For example, we identified people who were at risk of choking because staff were not supporting them to drink fluids in a safe way. In addition, nutritional risks were not accurately assessed or managed.

Care plans were not updated or did not include all the information staff needed to be able to care for people. For example, one person had lost weight, however their care plan review did not note this or provide guidance to staff on how best to support the individual with their nutrition.

Staff had not been supported to have the knowledge they required to effectively and safely care or support people.

The systems in place for assessing and monitoring the quality and safety of the service were not effective. This was because the shortfalls we found had not been identified by the service.

CQC is now considering the appropriate regulatory response to the shortfalls we found. Where providers are not meeting the fundamental standards, we have a range of enforcement powers we can use to protect the health, safety and welfare of people who use this service (and others, where appropriate). When we propose to take enforcement action, our decision is open to challenge by the provider through a variety of internal and external appeal processes. We will publish a further report on any action we take.

We spoke with 20 of the 31 people, four relatives, the representative provider and seven staff.

Below is a summary of what we found in the areas we looked at. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

At our inspection on 9 May 2014 we identified that people's care, treatment and support monitoring records were incomplete. This meant that according to the records we could not be sure they had received the right care, treatment and support. We did not specifically assess this area at this inspection. This was because the provider had not yet been required to submit an action plan detailing how they would address these shortfalls.

There were not enough nursing staff employed by the home and this meant that there was a high use of agency staff. This meant that there was not a stable nursing staff team who knew people and their needs.

We found there were eight occasions in a four week period when the staffing levels had fallen below the levels determined by the provider. This meant there were insufficient staff to ensure the health, safety and welfare to meet people's needs.

We found that the risks to some people were not consistently managed and planned for.

CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards. We found the location was not meeting the requirements of the Deprivation of Liberty Safeguards (DoLS). This was because they had deprived one person, who was staying at the home for short stay, of their liberty by preventing them leaving the home.

Is the service effective?

We saw that most people received care and support as described in their care plans. However, some people did not receive the care and support they needed and some care plans were not followed.

People were referred to health professionals, when staff were concerned or their needs changed.

Overall, people told us that they were happy with the care they received and felt their needs had been met. One person said: 'If I was scoring it out of 10, I would give it eight, if I want anything I've only got to ask and they sort it out'.

Is the service caring?

We observed that staff were sensitive, kind and caring in the way they treated people. They knew about them as individuals and how they liked to spend their time.

Is the service responsive?

We found that for most people their care plans had been updated as their needs or circumstances changed. However, for one person their needs had not been reassessed or planned for following an incident where they left the home unaccompanied.

Is the service well-led?

The acting manager and deputy manager had left the home and the representative of the provider and the area manager were providing management cover at the home until a new manager was appointed.

We also followed up on the shortfalls we identified in the administration of medicines.

We spoke with 11 of the 31 people, one relative, and four staff including the registered nurse on duty, the maintenance worker and the acting manager.

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

We found medications were managed safely and there were systems in place to audit medicines.

People's care, treatment and support monitoring records were incomplete. This meant that according to the records we could not be sure they had received the right, safe, care, treatment and support.

CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards. We found the location to be meeting the requirements of the Deprivation of Liberty Safeguards. Applications had been made as needed and proper policies and procedures were in place. The acting manager was knowledgeable about when applications needed to be made and how to do this.

Is the service effective?

We saw that people received care and support as described in their care plans. People were referred to health professionals, when staff were concerned or people's needs changed.

People told us that they were happy with the care they received and felt their needs had been met. One person told us: 'I can't ask for more I couldn't be happier if I was at home'.

Is the service caring?

People spoke positively about the care they received and that staff were kind, caring and compassionate. One person said: 'Carers treat me well here'.

People's privacy and dignity was maintained. This was because staff respected people's privacy by respecting their private spaces and maintaining their dignity during personal care.

Is the service responsive?

Peoples' needs had been reassessed and care plans were updated to reflect people's changing needs.

People had access to call bells and they were answered promptly. However the noise of the call bell system outside people's bedrooms and communal areas could impact on people's wellbeing.

Is the service well led?

The acting manager had implemented an action plan to meet the shortfalls identified at the last inspection. This included reviewing people's assessments and care plans, auditing medicines and assessing the competency of staff administering medications.

The acting manager had taken action following concerns being raised about the care at the home.

We spent time observing people in the main lounge during the morning and spoke with people in their bedrooms.

People we spoke with told us and we observed that they had mixed experiences of living at Kingland House. Comments from people included, 'I find it fine', 'Everyone is kind', and 'Staff are too busy they want to be running out of here'. A relative told us, 'They cope reasonably well'.

We found that people did not experience care, treatment and support that met their needs. This was because their needs were not fully assessed and planned for. People's care plans did not accurately reflect their needs and they were at risk of receiving unsafe or inappropriate care that did not protect their welfare and safety.

People were not protected from risks associated with medicines because the provider did not have appropriate arrangements in place to manage medicines.

Following the inspection the deputy general manager took action to ensure that the immediate serious concerns and shortfalls we identified were addressed. They have written to us to confirm the actions they have taken. This included making a safeguarding referral to the local authority.

People and visiting relatives spoke highly of the care they received and their experiences at the home. No one we spoke with had any complaints or concerns about how the home was run and managed. One person said 'If I want something, I just ask and they organise it and always with a smile', another person said 'I'm very happy with the care' and a relative said 'It's really good and we come in all the time and at different times'.

We saw staff were polite and caring in their interactions with people. People were relaxed with staff and told us that they got on well with them. One person said 'they are very very helpful'.

People's privacy, dignity and independence were respected and they experienced care and support that met their needs and protected their rights.

We found overall that there were systems in place to safely manage medicines. However, not all medications and creams had been administered as prescribed and the controlled drugs record was incorrect.

They were cared for by, suitably qualified, skilled and experienced staff that were safely recruited.

The provider had suitable quality assurance procedures in place to manage the health and welfare of people living in the home. People were able to comment on the service provided.

On the day of the inspection there were 20 people living at the home. We spoke with two staff and the newly appointed manager who started the day before the inspection.

We briefly spoke with people during our visit and observed that people were comfortable and relaxed throughout the home.

One person was admitted to hospital during the inspection. Staff responded quickly and appropriately to an emergency situation and a member of staff went with the individual to hospital to reassure them.