9 June 2023
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.
This inspection was carried out by 3 inspectors, 1 CQC staff member who observed the inspection 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
Kingswood Court is a ‘care home’ with nursing care. 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. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.
At the time of our inspection there was a registered manager in post.
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 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 9 people who lived at the home, 2 relatives, 8 staff members, the registered manager, deputy, regional director and the managing director.
We reviewed a range of records. This included 6 people’s care records in relation to risk assessments in place, 4 staff files in relation to their recruitment, medicines administration charts, health and safety checks and maintenance records. We looked at a variety of audits relating to the management of the home, people’s food and fluid charts and positional charts.
9 June 2023
Kingswood Court is a care home providing personal and nursing care for up to 66 people aged 65 and over. At the time of the inspection 46 people were living at the home. Accommodation is provided in one building over three floors.
People’s experience of using this service and what we found
Since the last inspection, improvements had been made to some key areas. However, we found that the governance system continued to be ineffective. Although we found no evidence that people had come to harm, we did identify shortfalls in relation to people’s records and monitoring of their wellbeing. Food and fluid charts were not consistently filled out by staff. Repositioning charts in place for people contained gaps. Further work to embed governance systems was required.
Improvements had been made in relation to staffing levels at the home. Staffing levels during the day had increased on some floors. The provider had successfully recruited into all care and nursing roles. Agency staff were used only when deemed necessary. The registered manager was mindful of any admissions to the home. Only those people’s needs that could be met were admitted to the home.
The medicines system was now safe. Medicines records confirmed people had their medicines safely. The actual time of administration was recorded by the nurses and safe gaps were left in between doses. The nursing staff confirmed they felt supported with their role. They now had more time to undertake other nursing duties that were previously impacted by staffing. People and their relatives told us staff were kind and looked after them well.
Improvements had been made with monitoring risks within the home. The staff were aware of guidance in relation to infection control. Observations of the staff were carried out to check that staff were compliant with wearing PPE safely. People were observed sitting in lounge chairs and no longer spent long periods of time in wheelchairs. Staff repositioned people in bed or assisted them to a table and chair to eat. This helped to minimise the risks of choking. People at risk of weight loss were referred to the GP with weekly weights taken.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was requires improvement (published 15 September 2022). We found there were breaches of 3 regulations.
We found at this inspection that improvements had been made with 2 breaches met, however, some other areas in relation to record keeping needed further improvement. This meant the provider remained in breach of one regulation.
Why we inspected
We carried out an unannounced inspection of this home on 12 April 2023. We identified several shortfalls. The provider completed an action plan after the last inspection to show what they would do and by when to improve the home.
We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the key questions safe and well-led which contain those requirements.
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 to good. This is based on the findings at this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Kingswood Court Care Home on our website at www.cqc.org.uk.
At this inspection, we have identified a breach of regulation in relation record keeping and good governance.
Please see the action we have told the provider to take at the end of this report.
We will continue to monitor the home and the intelligence we receive. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the home, which will help inform when we next inspect.