Kings Court Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. This is the first assessment for this service. This key question has been rated requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. The service was in breach of legal regulation in relation to safe staffing.
 

This service scored 44 (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 have a proactive and positive culture of safety based on openness and honesty. Whilst incidents and concerns were recorded and reviewed, systems for analysing information, learning lessons and embedding sustained improvements were not consistently effective. Opportunities to learn from concerns, incidents, feedback and performance information were sometimes missed. People, relatives and staff did not consistently describe a culture where concerns resulted in meaningful improvement. One relative told us they had repeatedly raised concerns about staffing levels and quality of care but felt little had changed. Another said there was limited feedback following concerns raised with management.
Staff also described challenges in raising concerns and seeing positive change. One staff member told us there had been limited support following management changes and another said concerns they had raised had not been resolved. Despite concerns relating to staffing levels, responsiveness and communication being raised over time, people continued to report the same issues during this assessment. This demonstrated the provider was not consistently using concerns, feedback and incidents as opportunities to learn and improve.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.
Several relatives told us communication regarding healthcare appointments, treatment changes and professional involvement was inconsistent. One relative explained they would have liked more information following GP visits, whilst another said they often needed to seek updates themselves.
We saw evidence of staff working with a range of healthcare professionals, including GPs, occupational therapists and speech and language therapists. During inspection activity, healthcare professionals were observed visiting the service and supporting people's health needs. However, Professional recommendations were not always reflected in care records or daily documentation in a timely manner, meaning information was not always transferred effectively between professionals and care staff.Risk-reduction measures were not always maintained. One person's sensor mat had been removed and relocated without a risk assessment, while another person experienced a fall where records showed a sensor mat had failed to activate. Documentation did not consistently demonstrate that actions had been followed up, reviewed or embedded to reduce the risk of recurrence.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

During the assessment, we identified incidents where records did not clearly demonstrate safeguarding risks had been recognised, reviewed and escalated in line with local procedures. Examples included allegations, medicines incidents and significant falls where documentation did not clearly show how safeguarding thresholds were considered, escalation decisions made, or appropriate action assured. We also found limited evidence of effective management oversight and follow-up, reducing assurance that safeguarding concerns were consistently identified and managed. As a result, people could not always be assured safeguarding risks were addressed in a timely and effective manner.

People's experiences of safety were mixed. Whilst many people told us they felt safe living at the service, some relatives raised concerns regarding delays in responding to requests for assistance and monitoring of people's wellbeing. One relative told us their family member had experienced several falls within a short period and questioned whether sufficient supervision and monitoring had been in place to reduce the risk of further incidents.
Despite these concerns, most people and relatives told us staff were kind, treated people respectfully and that they generally felt safe living at the home. Many spoke positively about the caring approach taken by permanent staff and did not report concerns about abuse or mistreatment.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Records showed several people experienced repeated falls despite existing risk management measures. In a number of cases, actions identified following falls were either delayed or not implemented before further incidents occurred. For example, one person experienced two falls within approximately 90 minutes of each other. Records identified follow-up actions and consideration of additional falls-prevention measures; however, documentation did not consistently demonstrate that identified actions were completed, reviewed or embedded to reduce the risk of recurrence. Another person experienced multiple falls over a three-week period, including an incident where a sensor mat failed to activate and there was no evidence the equipment had been tested or replaced following the event.
We found examples where equipment intended to reduce risk was not consistently available or appropriately managed. One person's sensor mat had been removed and relocated to another resident's room without a new risk assessment being completed, while another person's sensor mat control unit was left out of reach, contributing to a fall when they attempted to mobilise independently. Records also identified occasions where falls policies, multifactorial falls assessments and referrals to specialist services had not been completed following incidents.
Relatives raised concerns about how risks were managed in practice. One relative told us their family member had experienced repeated falls and questioned whether sufficient supervision and monitoring had been in place. Another reported concerns that post-fall observations and welfare checks had not always been completed as expected.
However, risk assessments were in place for areas such as falls, mobility, nutrition and skin integrity. We saw examples of staff adapting equipment and support arrangements when people's needs changed, and some relatives described staff as proactive in identifying and managing risks associated with mobility and healthcare needs.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. During inspection activity, we found two showroom bedrooms on separate floors were unlocked and accessible to people living at the service. These were secured only after inspectors brought the matter to the attention of staff. We also observed knitting needles stored in an unlocked communal area, creating a potential risk for people living with cognitive impairment.
People and relatives raised concerns about aspects of the environment affecting safety and independence. One person reported difficulties accessing outdoor areas because some doors were heavy and difficult to operate. Another relative described concerns that a resident could become unable to re-enter the building independently due to the design and operation of access doors. Concerns were also raised by a person that furniture arrangements in some communal areas restricted movement around the environment.
However, the home was generally clean, well maintained and free from clutter. We observed well-lit corridors and communal areas, emergency equipment was available, emergency call cords in assisted bathrooms reached floor level, and equipment checks and maintenance arrangements were in place. Many people and relatives described the environment as comfortable and welcoming.
 

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs. People and relatives described repeatedly raising concerns regarding staffing levels, delayed responses to requests for assistance, communication and service quality without seeing sustained improvement. One relative told us they had raised concerns with senior leaders on several occasions about understaffing, call bell response times and staff competence but felt there had been little improvement. They subsequently contacted The Care Quality Commission (CQC) because they did not feel their concerns had resulted in meaningful action.
Staff described staffing pressures as having a negative impact on care delivery. One member of staff told us they were "short staffed every shift" and said morale was very low. Another explained that staffing had become increasingly difficult following management changes.

We also found significant gaps in records relating to agency workers. Staff files reviewed lacked evidence of DBS checks, employment histories, references, conduct in previous roles and other information required to assure the provider that agency staff were fit to work with vulnerable people. The provider's heavy reliance on agency staff reduced assurance that people consistently received care from staff who knew them well, understood their needs and could provide continuity of support.

Despite these concerns, some people and relatives spoke positively about permanent staff and nursing staff. We observed caring interactions throughout the inspection, staff understood many people's individual needs, and some staff demonstrated good knowledge of specialist requirements such as dysphagia, diabetes and nutritional support.
 

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The provider had systems and processes in place to support infection prevention and control and reduce the risk of infection spreading within the home. We observed the environment to be clean, tidy and well maintained during both site visits. Communal areas, bedrooms and bathrooms appeared clean, and housekeeping staff were visible throughout the inspection. Relatives also consistently described the home as clean and well presented.
Care records showed consideration of infection-related risks. For example, staff monitored skin integrity, supported continence care, managed catheter care and documented interventions where people were at increased risk of infection or skin breakdown. Records also showed healthcare professionals were involved where required to support people's health needs.
However, we identified a small number of environmental oversight issues, including unlocked showroom rooms during inspection activity. Whilst these were not directly related to infection control, they indicated opportunities for stronger environmental monitoring. Overall, people were protected from the risk of infection through generally effective infection prevention and control arrangements.
 

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning. Care records identified examples where medicines monitoring and associated documentation required improved recording and oversight. For example, one person's records contained significantly elevated blood glucose readings, including readings above 20 mmol/L on several occasions. Records showed blood glucose monitoring was undertaken, insulin was administered and specialist healthcare professionals were involved in reviewing treatment. However, the provider's recording systems did not always clearly demonstrate clinical decision-making, review outcomes and how medicines-related risks were evaluated and monitored over time.
We identified areas where medicines governance and oversight required improvement, including aspects of recording systems, medicines administration documentation and the provider's oversight of medicines-related incidents.
However, people told us they generally received their medicines when required. Records showed medicines were administered by trained staff, regular blood glucose monitoring was undertaken where required, medicines storage arrangements were safe, and competency assessments were in place for staff responsible for administering medicines. We also saw evidence of healthcare professional involvement in reviewing people's treatment and health needs.