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Archived: Kingsthorpe View Care Home Good

The provider of this service changed - see old profile

The provider of this service changed - see new profile

All reports

Inspection report

Date of Inspection: 5 June 2013
Date of Publication: 10 July 2013
Inspection Report published 10 July 2013 PDF

People should get safe and appropriate care that meets their needs and supports their rights (outcome 4)

Not met this standard

We checked that people who use this service

  • Experience effective, safe and appropriate care, treatment and support that meets their needs and protects their rights.

How this check was done

We looked at the personal care or treatment records of people who use the service, carried out a visit on 5 June 2013, checked how people were cared for at each stage of their treatment and care and talked with carers and / or family members. We talked with staff, reviewed information sent to us by other regulators or the Department of Health and talked with other regulators or the Department of Health.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

Our judgement

People did not experience care, treatment and support that met their needs and protected their rights.

Reasons for our judgement

Relatives of people using the service told us, “My relative is content here," and, “I have found the manager very open to speak with. My [relative] has had some personal belongings go missing in the home. We have lost a number of pairs of trousers and they recently lost a new pair of glasses. I was very annoyed.”

To help us understand the experiences of people living in the home we used our SOFI (Short Observational Framework for Inspection) tool during the visit. The SOFI tool allows us to spend time watching what is going on in a service and helps us to record how people spend their time, the type of support they get and whether they have positive experiences.

During lunch we observed a person with discharge from their eye and a white substance round their mouth. The individual’s clothing had also lifted up potentially compromising their dignity. A staff member was sat beside and whilst looking at the person they made no attempt to adjust the individual’s clothing, clean their eyes or wipe their mouth. We provided feedback to the manager and they said they had asked a member of staff to address this.

We saw a person who had been positioned with their back to a loud television but were unable to move. There was no attempt made by staff to move the person to a quieter area so they could sit peacefully. We also observed a person being provided assistance to eat. Each time the person took a mouthful of food, the member of staff used a spoon to remove excess food which had been left on their face. The Deputy Manager informed us wet wipes were available in the lounge. This meant staff were not using the appropriate equipment to provide care and support to people within their care.

We looked at the care plans and associated risk assessments for eight people using the service. A care plan is a document which should identify a person’s needs and how staff can meet those needs, including assessments or identified risks for each person.

Care and treatment was not planned and delivered in a way that was intended to ensure people’s safety and welfare.

We found a number of records for people had not been completed. In one case we found a Malnutrition Universal Screening Tool (MUST) record dated back to March 2013, this person should have been monitored on a monthly basis. Within a separate care plan we found an individual’s MUST score had not been reviewed since April 2013, despite the eating and drinking plan stating this should be checked weekly. Another person’s care plan revealed the person had angina and their weight had increased by 4kg in the last month. There was no weight loss care plan or healthy eating guidance to support this person’s individual needs. This meant weight records and healthy dietary requirements were not being monitored effectively within the home.

One of the care plans for another person confirmed they had type two diabetes controlled by diet. There was no reference to a low sugar diet in the eating and drinking plan. The diabetes care plan stated blood sugar levels should be monitored weekly, including detail of the point at which a GP should be contacted, yet there was no reference to confirm what a low/high blood sugar level was within the care plan. The Deputy Manager confirmed blood sugar levels were monitored if the person appeared unwell.

We saw evidence in people’s care plans of GP and other professional involvement. However, within one care plan we found the involvement was not always sought in a timely manner. The care plan made no reference to intake of fluids, despite a reference within the daily records to encourage fluid as a urinary tract infection (UTI) was suspected. The home took 48 hours to call a GP in response to a suspected UTI. This meant people were not assured of receiving care appropriate to their needs and identified risks in a timely manner.

The staff we spoke to during our inspection felt the service provided good levels of care. We asked the staff how they maintain effe