Kingsbury Court

Updated 30 September 2022

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

The inspection was carried out by two inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Kingsbury Court 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. Kingsbury Court is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was not a registered manager in post. However, there was a home manager who had applied to register with CQC and supported the inspection.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with nine people who used the service and seven representatives of the people about their experience of the care provided. We spoke with 14 members of staff including the home manager, senior managers, a nurse, care staff, housekeeping staff and the chef.

We reviewed a range of records. This included elements of 13 people’s care plans and multiple medicines records for people supported with their medicines. We looked at recruitment checks and training records for three staff members. A variety of records relating to the management of the service, including policies and procedures were also reviewed.

Updated 30 September 2022

About the service

Kingsbury Court is a nursing and residential care home providing accommodation, personal care and nursing care to older people with physical support needs, some of who live with dementia. The home can support up to 60 people. At the time of our inspection there were 52 people using the service.

People’s experience of using this service and what we found

People’s experience of care was not always consistently good and safe due to staffing issues. There were not always enough suitably skilled staff effectively deployed in the home to ensure people were safely supported to mobilise freely, to manage their anxieties and day to day needs when they wished to have support and to take care of their wellbeing. This posed a range of risks to people, for example around falls, health deterioration or social isolation.

There was a new manager in post who made a range of positive changes around how people’s care was overseen. We saw positive changes were being made around how the quality was monitored, what support staff received on a day to day basis and how audit actions were followed up and completed. However, this was not consistent in the previous months and some outstanding actions had impacted on people’s experience of care they received and still needed addressing.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People and their relatives told us they felt safe with staff and in the home and overall staff were kind and caring. Where people needed support around their medicines, they received this safely. People’s individual risks were addressed in their care plans and action was taken when needed to keep people safe. People’s care was affected by staffing issues which we addressed with the provider.

New staff were recruited safely. Staff overall followed good infection prevention and control practice. Staff felt more supported in their roles since the new manager was employed and commented the culture of the service was slowly improving.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 07 August 2021)

Why we inspected

We received concerns in relation to staffing and risk management. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

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 from good to requires improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Kingsbury Court on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to staffing and governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

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.