Kingsthorpe View Care Home

Updated 6 September 2023

The inspection

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.

Inspection team

This inspection was carried out by 2 inspectors. An Expert by Experience carried out telephone calls to relatives of people using the service to obtain their opinion of the service. 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

Kingsthorpe View is a ‘care home’. 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. Kingsthorpe View is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager.

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.

Inspection activity started on 6 June 2023 and ended on 7 June 2023.

What we did before the inspection

The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We contacted Healthwatch for information they held about the service. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. We used all this information to plan our inspection.

During the inspection

We spent time observing care and support in the communal areas. We observed how staff interacted with people who used the service. We spoke with 2 people who used the service and 9 relatives of people who use the service. We spoke with the registered manager, the compliance manager, the area manager, nurses, senior staff, care staff, domestic staff and the cook. We reviewed a range of records. This included relevant parts of 8 people's care records and multiple medicine records. We looked at 3 staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

We spoke with the nominated individual during our inspection. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

After the inspection we continued to seek clarification from the provider to validate evidence found.

Updated 6 September 2023

About the service

Kingsthorpe View is a care home providing personal and nursing care for to up to 50 people. The service provides support to people living with a mental health diagnoses, dementia, physical disability or sensory impairment. The service accommodated 34 people at the time of our inspection in one adapted building, set out over two floors.

People’s experience of using this service and what we found

People living in the service were not safe and were placed at risk of harm. The environment, poor infection control processes, medicines management and lack of review of incidents at the service put people at risk.

The provider did not have effective quality assurance systems and processes in place to ensure improvements were identified where these were required at the service. The provider had failed to embed the improvements required from our last inspection

Staff had not received training in all areas relevant to people's health needs. People were left at risk of being supported by staff without the skills and knowledge to support their identified needs.

People’s oral medicines not given covertly were administered and disposed of safely. Staff involved in handling medicines had received training and recent competency checks around medicines.

Records relating to people's care contained information and guidance to enable staff to provide safe care and support for people. Risk management was in place for people who were at a high risk of falls and people who may present a risk to others from their behaviour. People's skin management and risk of falls or choking was effectively managed by staff.

Relatives and people told us that staff were understanding, patient and kind, and they gave positive feedback about the improving culture of the service and the management team.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

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 Inadequate (published 11 January 2023) and there were breaches of regulation in relation to people's safe care and treatment, staff being deployed to safely meet people's needs, safeguarding, person-centred care, consent to care and how well the service assesses and manages risks and improves the quality and safety of care.

The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found the provider remained in breach of regulations in relation to the assessment and management of risk, governance and the quality and safety of care.

Why we inspected

We carried out an unannounced inspection of this service on 6 and 7 June 2023. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve; safe care and treatment, staff being deployed to safely meet people's needs, safeguarding, person-centred care, consent to care and how well the service assesses and manages risks and improves the quality and safety of care.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements, including warning notices in Regulations 11 (Need for Consent), Regulation 12 (Safe Care and Treatment), Regulation 17 (Good Governance) and Regulation 18 (Staffing). This report only covers our findings in relation to the Key Questions Safe, Responsive and Well-led which contain those requirements.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Enforcement and Recommendations

We have found evidence that the provider needs to make improvements. Please see the Safe, Responsive and Well-Led sections of this report. The provider sent us evidence to show what action they had taken to the concerns we raised with them as part of this inspection. You can see what action we have asked the provider to take at the end of this full report.

We have identified breaches in relation to governance, assessment and management of risk and the quality and safety of care at this inspection. Please see the Safe and Well Led sections of this report.

Please see the action we have told the provider to take at the end of this report.

Follow up We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Kingsthorpe View Care Home on our website at www.cqc.org.uk.

Special Measures

This service has been in Special Measures since 11 January 2023. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

The inspection was prompted in part by notification of an incident following which a person using the service died. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of risk of falls. This inspection examined those risks.

You can see what action we have asked the provider to take at the end of this full report.

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 from Inadequate to Requires Improvement based on the findings of this inspection.