Background to this inspection
Updated
4 August 2023
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 Health and Social Care Act 2008.
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
This focused inspection was carried out by 1 inspector.
Service and service type
Kingsley House is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Kingsley House is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Registered Manager
This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.
As the provider was an individual there was no requirement to have a registered manager as they managed the service themself.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
We looked at all the information we held about the provider. This included the last inspection report, information we had received since the last inspection, such as notifications of incidents and other contact with the provider. We sought feedback from the local authority who work with the service. The registered manager had completed a Provider Information Return (PIR). The PIR is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.
During the inspection
We met the 3 people who lived at the service. We also met the registered manager and 1 staff member. We spoke to one relative of a person living in the home. We reviewed a variety of records relating to the management of the service, including policies and procedures. We looked at records used by the provider to manage the service which included the care plans for 3 people, records of audits and checks, and management records. We conducted a partial tour of the environment, which included an audit of infection prevention and control. After the inspection we continued to seek clarification from the provider to validate evidence found.
Updated
4 August 2023
About the service
Kingsley House 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. Kingsley House provides accommodation and personal care for up to 3 older people who were living with the experience of dementia. There were 3 people living at the service at the time of our inspection.
People’s experience of using this service and what we found
The provider did not always effectively operate quality assurance systems to oversee the quality and safety of the service. These systems had not identified shortfalls in the quality and safety of the service or ensured that expected standards were met.
People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests. Staffing levels did not support activities and people using the service did not always have access to activities inside and outside of the home.
The provider did not ensure consistent actions were taken to reduce risks to people and plans were not in place to minimise those risks. Staff were not appropriately supported in their role and they did not receive regular supervisions; spot checks and team meetings were infrequent.
There were infection prevention and control policies in place, however the provider did not always follow these. We found that the environment was not designed in line with best practice guidance for supporting people with dementia and we have made a recommendation about this.
Safe recruitment procedures were followed. Staff knew how to respond to possible safeguarding concerns. The staff were happy working at the service they knew people well.
The individual who was also the manager owned the care home. They worked with staff providing support for people using the service. They had a good knowledge of the individual needs of the people who were living there and had good relationships with them and the staff. People using the service and staff told us they felt managers were approachable.
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 good (published 17 August 2018).
Why we inspected
This inspection was prompted by a review of the information we held about this service.
This report only covers our findings in relation to the Key Questions Safe, Effective and Well-led. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed to requires improvement. This is based on the findings at this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Kingsley House on our website at www.cqc.org.uk.
Enforcement and Recommendations
We identified breaches in relation to safe care and treatment, good governance, staffing and need for consent. We have also made 3 recommendations for the provider to review best practice guidance to promote person centred care; supporting and involving people to maintain a balanced diet and follow best practice and guidance for providing an environment which meet people’s needs.
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 continue to monitor information we receive about the service, which will help inform when we next inspect.