Archived: Kingswood Manor

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. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of the legal regulation safe care and treatment which includes the management of medicines.

This service scored 38 (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 have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events to CQC. Lessons were not always learnt to continually identify and embed good practice.

At the last 2 assessments of this service, discussions took place with the registered manager and regional manager in respect of safeguarding events and what is and isn’t notifiable to CQC. This was because some events had not been reported to CQC appropriately. We found the same again at this assessment. There was a system in place to record, investigate and respond to safeguarding events. Some incidents of a notifiable nature however had still not been recognised as safeguarding and reported to CQC. This did not show effective learning had taken place to develop and improve the management team’s understanding of notifiable events or that lessons had been learnt to ensure safeguarding events were appropriately recognised and reported.

Some areas of learning and information were shared at staff and management meetings for example, in respect of record keeping and medicines. We found however these meetings were not fully effective in embedding learning and driving up improvements. For example, the learning and lessons to be learnt from the last 2 assessments of the service had not been successfully embedded and implemented to ensure compliance with regulatory requirements was achieved.

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

At the last 2 assessments of this service, people's needs prior to, and on admission, were not always properly assessed. Therefore, care plans were not always fully reflective or accurate in respect of their needs, risks and care. At this assessment we found the same. For example, some people living with dementia, did not have appropriate dementia care plans in place to advise staff on the type, nature and presentation of the person’s mental health to mitigate risks to their health and safety.

This impacted on the provider’s ability to work well with health care partners and ensure people’s safety and continuity of care was promoted when people moved between different services.

There continued to a significantly poor safety culture around the management of medicines. This impacted on the continuity of care, effectiveness and safety of people’s clinical treatment for medical and health conditions, placing their health and welfare at serious risk.

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.

Where incidents of a safeguarding nature had occurred, an appropriate investigation and referral to the Local Authority had been made to ensure people were protected from the risk of possible abuse. At the last two assessments of the service however, not all incidents of a safeguarding nature had been recognised as such, and reported appropriated to CQC. At this assessment, we also found one incident of neglect reported to CQC had not been reported with full transparency. This prevented CQC from making further enquiries about the circumstances of the incident. Despite discussions about safeguarding events and what needed to be reported to CQC at the last two assessments, no effective improvements had been made to ensure concerns were shared appropriately at all times.

People felt safe with the staff supporting them and told us staff were kind and caring. Relatives confirmed this. Staff had completed safeguarding training and knew what action to take should they suspect potential abuse.

There was a record maintained of all people living in the home who were subject to Deprivation of Liberty safeguards to protect them from harm.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

At the last assessment, some improvements to information about people’s needs and risks had been made, but further improvements were still required to ensure staff had clear and sufficient guidance on how to mitigate and manage risks. At this assessment we found the same. We found information about some people’s needs and risks was still not sufficiently detailed or clear. Some people’s care plans were not appropriately followed to ensure risks were mitigated.

Risks associated with people’s health and medical conditions were not always safely managed. People had not always been given the medicines they needed, as prescribed by their GP which placed people at risk of ill-health and at risk of experiencing the unwanted side effects and symptoms these medicines were prescribed to treat.

The provider did not always detect and control potential risks in the care environment. They did not always make sure that equipment, facilities and technology supported the delivery of safe care.

At the last 2 assessments concerns were identified with regards to the home’s fire doors and improvements were in progress. Prior to this assessment, Merseyside Fire Brigade confirmed the fire safety arrangements in the home were now satisfactory. The upstairs communal corridor’s carpet had also been replaced since our last visit to the home.

We found however other environmental improvements still required addressing. Some window frames remained rotted and some still had cracked window panes. Some toilet seats were loose which meant when sat on they slipped to the side. This was unpleasant and posed a falls risk to people with poor sitting balance. A radiator cover on the 1st floor corridor was not secured to the wall, and a curtain hung off the rail in one bedroom. One bedroom sink did not empty properly and made a loud chugging sound when it was being used which could be heard in the next bedroom. One bedroom also remained malodorous. The hot water in a significant number of bedrooms was not working properly and was lukewarm. This would have been unpleasant for people to wash and was ineffective for good hand hygiene purposes to prevent the spread of infection. The seating area in garden needed a clean and tidy. A dead bird was found under the wheelchair ramp leading to the garden area. There was also bird muck on the decking around the garden seating area.

There provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.

The provider had a tool in place to determine safe staffing levels. Some people felt there were enough staff on duty to meet their needs. One person felt they could do with more care staff. Another person told us when agency staff worked in the home, these staff did not always know what they were doing and did not know their routines.

Staff spoken with felt more care staff were needed in the morning to help people get up for breakfast. One staff member said, “Everyone wants to get up the same time”. Another said, “Senior carers get bombarded” with work. During our visit we did not observe any concerns with staffing levels, however we were not onsite to observe staff supporting people up for breakfast, which was the time stated by staff as a busy time.

The provider had staff profiles in place for agency staff which showed they had completed relevant training to do their job role. There was however insufficient evidence to show agency staff had had an appropriate induction into the home when employed to work there. We found the same issue for some new permanent staff. It is important new staff, including agency staff complete an appropriate induction to ensure they have the necessary knowledge, support and an understanding of the service, before working unsupervised. We discussed this with the registered manager and regional manager during the assessment. They provided no clear explanation as why induction records were not in place to evidence show staff had completed a robust induction process.

Overall, staff were recruited safely to ensure they safe and suitable to work with vulnerable people. The provider’s training records showed some staff training was overdue, and in need of refreshing. For example, 10 out of 37 staff had not completed or were overdue to refresh their training in dementia awareness and first aid.

The provider did not adequately manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The provider had policies and procedures in place in respect of infection control and prevention. Staff received training in infection control and were aware of what personal and protective equipment to use in the delivery of personal care. The home was satisfactorily clean on the days we were on site.

We found however the systems in place to mitigate the risk of Legionnaire’s disease developing in the home’s water supply were not robust. There was a Legionnaire’s risk assessment in place, but the risk management actions and checks identified in this risk assessment were not completed. We also found the facilities in place to observe good hand hygiene in communal toilets and bedrooms was not sufficient to prevent the spread of infection.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

At the last 2 assessments of this service, serious concerns with the management of medicines were found. At this assessment, no effective action had been taken to address these concerns, and the management of medicines remained unsafe.

Some people still did not receive their medicines as prescribed, because there was no stock of their medicines available in the home. Twelve people either missed doses of their regularly prescribed medicines or would have been unable to have doses of their ‘as and when required’ medicines as no stock was available. Medicines which were out of stock included antibiotics that were prescribed to be taken quickly in emergencies to treat a flare up of an infection without waiting to see the doctor. Other medicines out of stock included medicines for pain relief, the treatment of diabetes, long term antibiotics and laxatives. This placed people at risk of harm.

When people were discharged from hospital and changes had been made to their medicines, nurses failed to ensure changes to their medicines were acted upon swiftly. This meant people were either given medicines that had been discontinued or, there was a delay in people commencing on any newly prescribed medicines placing their health at risk of harm.

Time sensitive medicines including medicines to treat Parkinsons’ symptoms and strong pain relief medicines were still not always given with safe and appropriate time intervals between doses. This meant people may have been given their doses too close together or too far apart, placing them at risk of not having their symptoms treated safely.

When antibiotic creams were prescribed, nurses failed to follow the prescribers’ directions and did not apply them safely. This meant people were at risk of their infection not being fully treated and at risk of the infection returning or the bacteria becoming resistant to the creams. Records made in relation to the application of creams were also poor.

When people were prescribed medicines to be taken ‘when required’ (PRN) or with a choice of dose, the protocols to support their administration did not have sufficient guidance in place to ensure they were administered safely and consistently. It also meant staff still did not always have enough information, to tell them when someone may need their medicine. For example, the PRN protocols for the administration of laxatives failed to have information about when to start giving people their laxative, which resulted in people not having their bowels opened for 5 to 10 days on a regular basis. When different medicines or creams were prescribed to treat the same condition, nurses did not always have suitable guidance in place to determine which medicine or cream should be given first. Even when this information was clear, nurses failed to follow the protocols. This placed people at risk of avoidable harm.

When medicines needed to be given via a feeding tube nurses did not make clear records about how the tube was looked after to make sure it did not become blocked. During the inspection paper records were put in place but these were not properly completed.

Waste medicines were still not stored safely in line with current guidance. One person was given eyedrops that were out of date placing them at risk of an eye infection. Medicines stored in the fridge including insulin had been stored at temperatures higher than the safe temperature advised by the manufacturers.

Nurses had been assessed as being competent to administer medicines. However these assessments had been completed by a nurse employed at the service, who had been previously identified as not always managing medicines safely. This raised concerns over the robustness of these assessments.