Archived: Kingswood Manor

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.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained the same. This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

The service was in breach of legal regulation safe care and treatment.

This service scored 42 (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 always make sure people’s care and treatment was effective because they did not always ensure people’s needs were fully assessed and managed.

At the last 2 assessments, the processes in place to assess and review people’s needs and care have required improvement. At this assessment we found the same.

Not all of people’s needs were properly assessed. For example, one person’s oral health and pain levels were not fully assessed which meant staff lacked information and guidance on how to support them effectively. Two people’s dementia care was not properly assessed and planned. Some people’s care records still contained contradictory information about their needs and risks in areas such as mobility, mental capacity, continence, skin integrity and communication. In addition, where people’s needs had changed, care plans had not always been updated appropriately. Some people had complex needs such as a feeding tube (Percutaneous Endoscopic Gastrostomy or PEG) in place or a catheter, we found assessment information was not always clear or sufficient.

The provider did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards.

People and their relatives felt the care they received met their needs. We found however serious shortfalls in the delivery of people’s care with regards to medicines and aspects of clinical care. The management of medicines was unsafe, and nursing staff did not adhere to best practice guidance published by CQC and the Royal Pharmaceutical Society. There were also shortfalls in the delivery of PEG care (Percutaneous Endoscopic Gastrostomy), catheter care and bowel management due to best practice guidance issued by The National Institute of Health Care Excellence not being followed. These shortfalls placed people at risk of avoidable harm.

The Mental Capacity Act 2005, legislation designed to protect people’s legal right to consent was intermittently followed, which meant legal consent to some specific decisions had been obtained appropriately, whereas others had not. For example, the registered manager or a relative had consented to some decisions on behalf of people without evidence of them having the legal authority to do so.

Tjhe provider did not always work well across teams and services to support people.

When people had been discharged from hospital we found the transition back to the care home was not adequately managed. Some people’s medicines had changed post discharge from hospital but on return to the home, this was not always picked up and acted upon by nursing staff. This meant some people continued to receive medicines that were either no longer prescribed or did not receive the new medicines prescribed for them when in hospital.

The lack of accurate and clear information increased the risk of inaccurate or out of date information being shared with other services and professionals when additional support was needed.

Care staff and nursing staff in the home worked well as a team. There was a daily handover process which ensured information about people’s ongoing needs and care was shared between shifts. A multi-disciplinary meeting also took place weekly with nursing staff, the home’s registered GP, community matron and other health and social care professionals, wherein concerns in relation to people's health needs were discussed with them.

The provider did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control. Staff did not always support people to live healthier lives, or where possible, reduce their future needs for care and support..

People and their relatives told us they received enough to eat and drink. We saw people were offered regular drinks and snacks by care staff. One person told us, “The food is ok, it would be better if it was hotter. A hot charging plate would be good, it’s good quality and the chef is very good if you don’t want what’s on offer, they do offer alternatives”.

During our visit we observed some meals left on the kitchen top for over 20 minutes before being served. It is likely this food would have been lukewarm. We intervened for one person’s meal which had sat on the kitchen top for 30 minutes. The staff member took it back down to the kitchen to get it re-heated.

Another said, “I don’t think the chef knows the meaning of the word puréed because it has lumps in it sometimes so I then can’t eat all of it”. We checked with the chef and the catering assistant if they had guidance on people’s special dietary requirements. They told us they did but were unable to find this guidance during our visit. We raised this with the registered manager and regional manager and they directed catering staff as to where to find this information.

Records showed referrals to other services and other health and social care professionals were made in support of people’s health and wellbeing. This included referrals to speech and Language Therapy, occupational therapy, mental health and dietician in support of people’s needs. People told us and we saw people being supported with their independence in respect of their mobility and nutrition.

The provider did not adequately monitor people’s care and treatment to continuously improve it. They did not always ensure outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

At the last 2 assessments of the service, positive outcomes in the delivery of care were hindered by significant shortfalls in safe care and treatment, including medicines and the management of the service. At this assessment we found the same.

Some people’s health continued to be placed at risk because they did not always receive the medicines they needed, or as prescribed. Some people did not receive the creams prescribed to treat skin conditions. This impacted on people’s health and wellbeing as the care they received did not meet clinical expectations and the expectations of people themselves. The clinical oversight and monitoring of people’s health conditions and medicine management remained poor and ineffective.

PEG and catheter care was not always properly or safely provided, which impacted the ability of people to achieve positive outcomes in these areas. People were also placed at risk of discomfort and pain by a failure to ensure robust bowel monitoring and action was taken when signs of constipation were identified

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 and their relatives told us staff always sought their consent before any support was provided. They told us staff were respectful and helpful. One person told us, “They (Staff) keep wanting me to go downstairs but at the moment I’m not ready for that, so they respect that”. Another person was encouraged by staff to have their lunch at the dining room table. They did not want to do this, choosing to remain in their lounge chair. Staff supported them with this choice and provided them with an over the knee table so they could eat their meal where they preferred.

Where there were concerns about people’s capacity to make informed decisions, the Mental Capacity Act (MCA) 2005 had been followed for some decisions. For example, in relation to them living in the home, deprivation of liberty safeguards, bed rails, use of assistive technology and do not resuscitate decisions. The involvement of how people with communication difficulties were supported to participate in these decision-making processes remained unclear.

Decisions in respect of whether the person consented to the provider taking photographs of them and sharing their information with other parties, had not been subject to the MCA legislation. The registered manager has signed to consent to these decisions on their behalf when they did not have the legal authority to do so.

It was clear the application and understanding of the MCA within the home continued to require improvement to ensure people’s rights to consent to their care were fully respected.