Kingswood House

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence. This is the first assessment for this service. This key question has been rated inadequate. This meant there were widespread and significant shortfalls in people’s care, support and outcomes.

This service scored 29 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not make sure people’s care and treatment was effective because they did not effectively assess people’s health, care, wellbeing and communication needs. The service assessed people’s needs prior to the commencement of care, however these assessments contained lots of generalised information about the service and lacked detail about how the person would be cared for at the service. Pre-admission assessments contained information about the types of assessments that would be undertaken after the person moved to the service, however, during the inspection, plans were found to be lacking all necessary assessments. For example, 1 person did not have a sensory needs assessment despite this being a known area of need. Another person at the service had not had an assessment completed of their capacity and ability to manage their health needs.

The provider did not plan and deliver people’s care and treatment with them effectively. They did not follow legislation and current evidence-based good practice and standards. The provider had not ensured staff followed their own policies in relation to reducing restrictive policies. Information from records was not utilised to improve practice. Staff did not always have the correct skills or competencies to meet the needs of people at the service. Although the provider did take immediate corrective actions to deliver appropriate training to staff when requested to do so, the provider had failed to proactively identify and address this issue.

The provider did not always work well across teams and services to support people. The service worked on a staff rotation model, meaning all staff worked with all people for a period of time every day. For some people at the service this meant they may have different staff allocated to them every 2 hours. Some people and relatives expressed this did not meet their needs and led to inconsistencies in approach. People told us, “Some staff follow me about, I don’t get time alone, but some staff do give me time.” and, “Sometimes there are too many staff. I don’t like the changes in staff.” The quality of communication within the service was variable. Relatives told us information was passed on repeatedly to the service but not actioned. A relative told us, “There are communication issues at all levels. We have to ring frequently, I only have confidence speaking to the admin staff due to the changes in staffing.”

The provider did not support people to manage their health and wellbeing, so people could not maximise their independence, choice and control. Staff did not support people to live healthier lives, or where possible, reduce their future needs for care and support. People did have plans in place around managing health needs however these were not always sufficiently detailed, and some records relating to people’s capacity and capability to meet their health needs were missing. Poor communication and a lack of organisation within the service had led to people missing important appointments. Relatives told us, “I have to add appointments to their diary as they were being missed.” and, “I have had to speak to staff about being late to [relative’s] appointments. The staff hadn’t brought important items to previous appointments.” Inspectors observed confusion on site about an appointment in the diary. The recording was unclear, and it was not obvious to staff where a meeting regarding a person at the service was taking place or who from the service should attend.

The provider did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves. There was a lack of evidence that records were reviewed to assess the standard of the care people received or to attempt to improve outcomes for people. Information contained within records was of poor quality, making it difficult to assess people’s progress or areas to improve. Important assessments about people’s needs and the level of assistance required were sometimes missing.

The provider did not always tell people about their rights around consent and did not always respect their rights when delivering care and treatment. People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that although requests for authorisation were submitted, and conditions in place abided by, some records did not contain important information. For example, one application for DoLS did not include information about restrictive practices which were used often. There was no evidence to suggest this had been reviewed or an update sent to the supervisory body to make them aware of restrictive practices which were not outlined in the original application.