Kingston House is registered to provide accommodation and personal care for up to 46 people. At the time of our inspection there were 42 people living at the service. Kingston House is divided into three sections, Primrose, Tulip, and Lavender Lodge. Primrose and Tulip are residential areas of the home, with shared lounges and a dining room. People living in Lavender Lodge have a diagnosis of dementia. Lavender Lodge was accessible through key coded secure doors. Lavender Lodge had a separate lounge and dining room, although the whole home came together for some activities.This inspection was unannounced and took place over two days. The inspection commenced on 19 September 2018 and we returned 20 September 2018. We previously inspected the service in April 2017 and found three breaches of The Health and Social Care Act 2008. At this inspection we found two breaches in regulation, one of these was a repeated breach from the previous inspection.
At the previous inspection, in March 2017, we found the service to be in breach of three regulations. We found that there were not sufficient staff to meet people’s needs. Where people lacked the mental capacity to consent to care and treatment, decisions were not always made by someone with the appropriate legal authority. The quality and consistency of records meant that there was no overview of the support people received. People’s care plans did not reflect their care needs. Also, the systems in place to monitor the quality of the service failed to identify the shortfalls found during the inspection.
During this inspection, we found improvements had been made so that the service was no longer in breach of two regulations. There was appropriate mental capacity assessment documentation in place. Where people had representatives with Lasting Power of Attorney (LPoA), this was documented, with a copy kept on file. This meant the service knew who to contact in relation to decisions and the LPoA had the legal authority to act on the person’s behalf. There were also improvements in staffing and the service was fully staffed.
We found a continued breach of Regulation 17 of the Health and Social Care Act 2008, regarding good governance. This was because appropriate action had not been taken to address shortfalls in quality monitoring systems. There were areas of concern identified at the inspection that had not been recognised as part of the audit and monitoring checks completed by the management team. We also found breaches in Regulations 9 regarding person-centred care and 12 for safe management of risk.
Risks were identified where people could not use their call bell. However, there were no directions for staff around how they should reduce these risks.
Where people were prescribed creams and lotions, the protocols did not explain where and when staff should administer these. Record keeping for cream and lotion administration was not always completed, and did not evidence that people received their prescribed cream as directed.
Where accidents happened, these were recorded and monitored; however, body maps for injuries were not followed up. Where injuries had occurred, these were recorded, but there were no progress notes. We saw reference to a carer finding bruising on a person in the daily notes. There was no body map or accident form completed regarding this. Where one person had experienced frequent falls, the accident form stated in the management notes that a risk plan would be implemented. We saw that this had not been implemented following the accident.
Food and fluid intake monitoring for people who were at high risk of malnutrition and weight loss was not documented in a consistent manner. The recording system was not being used appropriately. This meant that there was no overview of how the service was meeting people’s identified needs with regards to their nutrition.
Record keeping around activities and social interactions varied in quality and consistency. There were large gaps in the record entries for some people and for others the quality of records did not demonstrate that interactions of value had taken place. It was not possible during the inspection to fully identify if this meant that people did not receive interactions, or if there was a recording issue. This meant there was no true picture to gauge if a person was at risk of social isolation.
People living in different parts of the home received different dining experiences. The experience of those living in Primrose was more positive and promoted choice and independence greater than those living in Lavender Lodge. We saw a limited choice of drinks made available during meal times. Tables were not laid with place settings. Staff did not show people a visual choice of meals. There were no menus or menu boards available to show what was available through words or pictures. Staff did not explain to people what was on their plate before they ate it. Some people due to their dementia or visual impairments would not be able to easily identify the food types.
Staff training was not always up to date. However, training was planned to address the shortfalls.
There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (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 2008 and associated regulations about how the service is run.
People and their relatives told us staff were kind and caring. People shared positive feedback with us about staff recognising when they were feeling unwell, or ‘out of sorts’. The GP told us they felt staff knew people well.
Complaints were investigated. We saw records showing that complaints were explored and responded to appropriately.
The service received compliments and thank you cards from relatives where their family member had received end of life care. People and relatives thanked staff for feeling like a family to the person, and for their kind approach.
There were end of life care plans in place. These documented people’s future wishes, including funeral plans and who they would like to have present, as well as their preference to be at the home or in hospital.
Staff told us they enjoyed working at the service. They said they felt supported by the management team and had been encouraged to develop.
A ‘champion’ system had been implemented. Staff were responsible for leading on certain aspects of the service. For example, there were champions for continence, dignity, and infection control.
There were strong community connections and an activity schedule including activities and events inside and out of the home. The service fundraised money for the local memory club; and for updating equipment and fittings in the home.
Relatives were welcome to visit when they wished. We saw that events took place where relatives could join their family members. For example, fundraising bingo nights. The registered manager told us this was a free, but ticketed event to ensure they knew who was expected and visiting.
People’s religious and spiritual beliefs were supported. There was a quiet room where people were receiving a religious reading. There was also a church a short walking distance from the home, where people regularly attended services and events.
Staff were respectful of people’s needs and privacy. We saw altercations being diffused in a dignified manner, with staff respectful of both people’s perspectives and opinions. Staff spent one to one time with people to help de-escalate challenging behaviours.
We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
This is the second time the service has been rated as Requires Improvement. In line with our published guidance for repeated Requires Improvement, CQC will be considering what enforcement action to take. 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.