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Archived: Kingsley Court

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Inspection report

Date of Inspection: 3 June 2011
Date of Publication: 20 September 2011
Inspection Report published 20 September 2011 PDF

People should be protected from abuse and staff should respect their human rights (outcome 7)

Not met this standard

We checked that people who use this service

  • Are protected from abuse, or the risk of abuse, and their human rights are respected and upheld.

How this check was done

Our judgement

The provider is not compliant with this outcome because the organisation’s management, reporting and monitoring systems have not protected people from the risk of abuse.

User experience

The people we spoke with during our unannounced visit, on 03 June 2011, did not raise any concerns regarding their safety, the quality of the service or the staff supporting them. We observed that people were relaxed and comfortable in their surroundings.

Other evidence

We carried out this review of the service because of concerns regarding the safety of people living at Kingsley Court, which were identified through notifications sent to us by the manager and reports from local authority safeguarding investigations. These concerns included reports of two serious incidents of assault within the service on 19 and 20 April 2011 and possible financial irregularities. Hertfordshire County Council led a multi-agency safeguarding of vulnerable adults investigation. The outcome of the safeguarding investigations and independent financial audit, commissioned by the provider as part of the review, identified a failure to keep adequate financial records, lack of robust policies and procedures for managing money belonging to people who use the service and monitoring of management arrangements. Not all incidents that took place within the service were considered and reported under safeguarding procedures. This means people may not be protected from abuse because appropriate management arrangements were not provided and professionals who represent people living at Kingsley Court were not kept informed regarding the nature and severity of some incidents so they could take further action if required. The provider has sent us a copy of the action plan put in place following the financial audit, to ensure there are adequate controls and oversight of financial procedures. We have not yet had the opportunity to see the outcome of this in relation to people who use the service because the service is currently closed.

While this review was in progress the provider informed us of their intention to temporarily close Kingsley Court so the company could carry out a review of the type of service provided from this location. We were advised the decision was not related to the investigations currently taking place but was taken for operational reasons. Arrangements had been put in place to provide the seven people currently living at Kingsley Court with support from their representatives and commissioning authorities.

We carried out a joint unannounced visit to Kingsley Court, on 03 June 2011, with a social worker from Hertfordshire County Council, as we had received information that the acting manager had been suspended by the provider, with immediate effect, in relation to issues identified at another service. This meant we were concerned about the stability of the management arrangements during this vulnerable period when people were moving out.

During our visit to the service we noted a lack of leadership and confidence among the staff present, which meant standards, had slipped in some areas. These included; a delay in administering someone their medicine because staff had not followed the company procedure for recording the information on the administration chart, staff not feeling empowered to cover unexpected gaps in the rota arising out of staff sickness, odour in an area of the home and reduced stocks of fresh food, such as fruit, in the kitchen.

The area manager for the service arrived during our visit with the person who was to take over as acting manager. We were able to have a full discussion about the concerns we had identified during our visit. A plan was developed to keep us notified of the action taken and support being provided to the people living at Kingsley Court to maintain the safety and quality of the service as they moved to alternative accommodation. Following our visit evidence of the action taken by the provider to address the issues we had raised was sent to us.