• Care Home
  • Care home

Queens Court

Overall: Inadequate read more about inspection ratings

21 Bickley Road, Bromley, Kent, BR1 2ND (020) 8468 7440

Provided and run by:
Lorven Housing Ltd

Important: The provider of this service changed. See old profile
Important:

We served a warning notice on Lorven Housing Ltd on 9th September 2024 for failing to meet the regulation related to safe care and treatment including maintaining person-centred records, the management of medicines and to monitor and mitigate risks to the health, safety, and welfare of people. Lorven Housing Ltd failed to meet the regulation related to the management and oversight of governance and quality assurance systems at Queens Court.

Report from 6 June 2024 assessment

On this page

Well-led

Inadequate

Updated 13 November 2024

We found there no clear and effective governance. Records were not always contempraneous, and assessments were not always in place or appropriately completed. There were no safeguarding audits, complaints logs, or accidents and incident analysis tools in place. Audits and quality assurance tools failed to identify issues we found at the assessment. This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This service scored 36 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Shared direction and culture

Score: 1

There was a system of audits and quality assurance checks in place, for some areas but these were not effective, as they had not identified all the issues we found with care plans, risk assessments and medicines. There were no safeguarding adults, complaints logs, accidents and incidents or analysis tools in place. The deputy manager told us they were working to develop tools for monitoring and reviewing safeguarding adult’s concerns, complaints and accidents and incidents. A quality assurance audit conducted on 26 June 2024 stated under effective that regular reviews of people’s care plans and risk assessments took place. The person-centred care the audit recorded ‘detailed person-centred care plans are in place for all residents.’ The ‘governance, management and sustainability’ audit recorded ‘Some internal QA systems are in place.’ However, we found that information and processes were not in place and or lacking information and they were not used effectively to monitor and improve the quality of care. The providers quality assurance systems in place failed to identify the issues we found during our assessment of the service. This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

There were regular staff meetings. Issues discussed at recent meeting included kitchen management, cleaning issues, confidentiality, knowing our duties, being responsive, safeguarding, health and safety, training and teamwork. Staff told us the registered manager was approachable and listened to them.

Capable, compassionate and inclusive leaders

Score: 1

The registered manager told us they were available over the phone if staff needed their advice. They contacted the service regularly to ensure that everything was running smoothly. They said the operational manager was also available over the phone for advice as required. The operational manager told us they regularly visited the service to provide supervision and support to the registered manager and deputy manager. However, we found the service was not always well led and there was a lack of systems in place to ensure good oversight. The current management arrangements and oversite at the service was failing to ensure that peoples care, support and risk to their safety were not being appropriately assessed and met.

There was a system of audits and quality assurance checks in place, for some areas but these were not effective, as they had not identified all the issues we found with care plans, risk assessments and medicines. There were no safeguarding adults, complaints logs, accidents and incidents or analysis tools in place. The deputy manager told us they were working to develop tools for monitoring and reviewing safeguarding adult’s concerns, complaints and accidents and incidents. A quality assurance audit conducted on 26 June 2024 stated under effective that regular reviews of people’s care plans and risk assessments took place. The person-centred care the audit recorded ‘detailed person-centred care plans are in place for all residents.’ The ‘governance, management and sustainability’ audit recorded ‘Some internal QA systems are in place.’ However, we found that information and processes were not in place and or lacking information and they were not used effectively to monitor and improve the quality of care. The providers quality assurance systems in place failed to identify the issues we found during our assessment of the service. This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Freedom to speak up

Score: 2

The registered manager told us they took people’s views into account. They received feedback through residents and relatives’ meetings. They told us they used the feedback from people to make improvements at the service.

There was a whistle blowing policy in place for staff to follow if they witnessed poor practice. However, there was no robust safeguarding procedures or processes in place, or systems to provide the right level of scrutiny and oversight to identify, assess and respond to safeguarding concerns. Regular residents and relative's meetings were held. Issues discussed at recent relatives meeting included refurbishment at the service and the garden, planning for people’s care needs, nutrition and hydration and activities. The minutes included questions from family members and responses form the provider and management team.

Workforce equality, diversity and inclusion

Score: 2

Staff had received training on equality and diversity. They told us they worked in a multicultural staff team, and they had no issues supporting people with diverse needs and backgrounds. We saw the providers training matrix. Training records showed that some staff were not always up to date with required learning. The registered manager managed another care service owned by the provider. They worked at the service 3 days each week. There was a deputy manager in post working at the service 5 days a week in the absence of the registered manager.

There were regular staff meetings held, and staff confirmed their attendance. Issues discussed at recent meeting included kitchen management, cleaning issues, confidentiality, knowing our duties, being responsive, safeguarding, health and safety, training and teamwork. However, records showed there were no clear and effective governance, management, and accountability arrangements in place to oversee the service delivery and ensure people's safety.

Governance, management and sustainability

Score: 1

The registered manager told us they did not have a safeguarding adults or complaints log and analysis tool in place. The deputy manager told us they were working on logs for safeguarding adults, complaints and accidents and incidents. The operational manager told us about improvements planned. These included areas such as improving the décor and making the service more dementia friendly. They told us they carried out regular safety checks and quality assurance audits.

There were no robust, clear and effective governance, management and accountability arrangements in place to oversee the service delivery and ensure peoples safety. Records were not always contemporaneous. and did not provide sufficient or accurate information. Care records were reviewed, however they were not always person centred, and lacked detail and were contradictory and confusing in parts. The provider showed us a quality compliance audit for June 2024. This covered the CQC’s 5 key questions safe, effective, caring, responsive and well led. The audit failed to pick up the issues we identified during our assessment. We found that the registered manager had failed to notify CQC of an incident where a person using the service left the service and sustained an injury that required hospital treatment. A safeguarding concern was not raised nor the local authority was not notified. This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Partnerships and communities

Score: 2

Most people had access to health care professionals when they needed them.

The deputy manager told us the home had positive links with community services such as district nurses and community mental health teams. The home’s activity coordinator told us they attended regular forums for care home activity coordinators organised by the local authority. We saw a poster and the deputy manager confirmed that the home had recently held a charity coffee morning and raised money to support people living with cancer.

Partners told us staff and managers managed the people’s medical needs well. A visiting professional told us they had some concerns about wound care and management at the service and they would raise this with the manager during their visit and their manager when they returned to their office.

The registered manager told us they worked with the local authorities commissioning team.

Learning, improvement and innovation

Score: 1

We saw the service worked closely with the local authority commissioning team.

The provider failed to ensure there were effective systems in place to monitor the quality and safety of the service. There were no safe and effective systems to assess, monitor and improve the care and support provided to people. Audits in place to review and monitor care plans and assessments, did not identify that people’s needs, risks and wishes were fully assessed and documented appropriately and failed to identify the concerns we found at this assessment. There were no systems in place to ensure continuous learning, innovation and improvement across the service.