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.