Kingston House

Kingston House is a care home providing personal care to 36 people aged 65 and over at the time of the inspection. The service can support up to 46 people. People live in three wings, one of which specialises in providing care to people living with dementia.

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

People said they felt safe living in the home and staff supported them to manage the risks they faced. People received support to take the medicines they had been prescribed. We have made a recommendation about supporting people to manage their medicines independently. There were enough staff to provide the care that people needed.

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.

People liked the food provided by the home and staff helped people where required. People were able to access the health services they needed. Staff received suitable training to give them the skills to meet people’s needs. The registered manager provided good support for staff to be able to do their job effectively.

People received caring and compassionate support from kind and committed staff. Staff respected people’s privacy and dignity. People and their relatives were positive about the care they received and about the quality of staff.

People were supported to take part in activities they enjoyed. People were involved in planning the activities schedule. There were opportunities for people who were unable to participate in group activities, to help ensure they did not become socially isolated. People had been supported to develop care plans that were specific to them. These plans were regularly reviewed with people to keep them up to date.

The service was well-led, with a registered manager and experienced management team. People felt the management team had a good understanding of any issues in the home. The quality of the service was regularly assessed, and action taken to make improvements where needed.

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 23 October 2018) and there were breaches of regulations. 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 improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

This inspection was unannounced and took place over two days. The inspection commenced on 19 September 2018 and we returned 20 September 2018. We previously inspected the service in April 2017 and found three breaches of The Health and Social Care Act 2008. At this inspection we found two breaches in regulation, one of these was a repeated breach from the previous inspection.

At the previous inspection, in March 2017, we found the service to be in breach of three regulations. We found that there were not sufficient staff to meet people’s needs. Where people lacked the mental capacity to consent to care and treatment, decisions were not always made by someone with the appropriate legal authority. The quality and consistency of records meant that there was no overview of the support people received. People’s care plans did not reflect their care needs. Also, the systems in place to monitor the quality of the service failed to identify the shortfalls found during the inspection.

During this inspection, we found improvements had been made so that the service was no longer in breach of two regulations. There was appropriate mental capacity assessment documentation in place. Where people had representatives with Lasting Power of Attorney (LPoA), this was documented, with a copy kept on file. This meant the service knew who to contact in relation to decisions and the LPoA had the legal authority to act on the person’s behalf. There were also improvements in staffing and the service was fully staffed.

We found a continued breach of Regulation 17 of the Health and Social Care Act 2008, regarding good governance. This was because appropriate action had not been taken to address shortfalls in quality monitoring systems. There were areas of concern identified at the inspection that had not been recognised as part of the audit and monitoring checks completed by the management team. We also found breaches in Regulations 9 regarding person-centred care and 12 for safe management of risk.

Risks were identified where people could not use their call bell. However, there were no directions for staff around how they should reduce these risks.

Where people were prescribed creams and lotions, the protocols did not explain where and when staff should administer these. Record keeping for cream and lotion administration was not always completed, and did not evidence that people received their prescribed cream as directed.

Where accidents happened, these were recorded and monitored; however, body maps for injuries were not followed up. Where injuries had occurred, these were recorded, but there were no progress notes. We saw reference to a carer finding bruising on a person in the daily notes. There was no body map or accident form completed regarding this. Where one person had experienced frequent falls, the accident form stated in the management notes that a risk plan would be implemented. We saw that this had not been implemented following the accident.

Food and fluid intake monitoring for people who were at high risk of malnutrition and weight loss was not documented in a consistent manner. The recording system was not being used appropriately. This meant that there was no overview of how the service was meeting people’s identified needs with regards to their nutrition.

Record keeping around activities and social interactions varied in quality and consistency. There were large gaps in the record entries for some people and for others the quality of records did not demonstrate that interactions of value had taken place. It was not possible during the inspection to fully identify if this meant that people did not receive interactions, or if there was a recording issue. This meant there was no true picture to gauge if a person was at risk of social isolation.

People living in different parts of the home received different dining experiences. The experience of those living in Primrose was more positive and promoted choice and independence greater than those living in Lavender Lodge. We saw a limited choice of drinks made available during meal times. Tables were not laid with place settings. Staff did not show people a visual choice of meals. There were no menus or menu boards available to show what was available through words or pictures. Staff did not explain to people what was on their plate before they ate it. Some people due to their dementia or visual impairments would not be able to easily identify the food types.

Staff training was not always up to date. However, training was planned to address the shortfalls.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the service is run.

People and their relatives told us staff were kind and caring. People shared positive feedback with us about staff recognising when they were feeling unwell, or ‘out of sorts’. The GP told us they felt staff knew people well.

Complaints were investigated. We saw records showing that complaints were explored and responded to appropriately.

The service received compliments and thank you cards from relatives where their family member had received end of life care. People and relatives thanked staff for feeling like a family to the person, and for their kind approach.

There were end of life care plans in place. These documented people’s future wishes, including funeral plans and who they would like to have present, as well as their preference to be at the home or in hospital.

Staff told us they enjoyed working at the service. They said they felt supported by the management team and had been encouraged to develop.

A ‘champion’ system had been implemented. Staff were responsible for leading on certain aspects of the service. For example, there were champions for continence, dignity, and infection control.

There were strong community connections and an activity schedule including activities and events inside and out of the home. The service fundraised money for the local memory club; and for updating equipment and fittings in the home.

Relatives were welcome to visit when they wished. We saw that events took place where relatives could join their family members. For example, fundraising bingo nights. The registered manager told us this was a free, but ticketed event to ensure they knew who was expected and visiting.

People’s religious and spiritual beliefs were supported. There was a quiet room where people were receiving a religious reading. There was also a church a short walking distance from the home, where people regularly attended services and events.

Staff were respectful of people’s needs and privacy. We saw altercations being diffused in a dignified manner, with staff respectful of both people’s perspectives and opinions. Staff spent one to one time with people to help de-escalate challenging behaviours.

We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This is the second time the service has been rated as Requires Improvement. In line with our published guidance for repeated Requires Improvement, CQC will be considering what enforcement action to take. Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

A registered manager was in post when we inspected the service and was available and approachable throughout our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. At our previous inspection the home received a rating of good overall and a rating of outstanding in the responsive domain. At this inspection we found areas requiring improvement which was not consistent with the previously awarded rating.

There were sufficient staff to meet people’s basic care needs. However there was not always enough staff available to meet the high level of social and emotional needs present in the dementia unit of the home. During our inspection we observed incidents that were not effectively managed due to a lack of available staff.

The home had risk assessments in place; however they were not always in place for all identified risks to people. We found that risks for individual people would sometimes be mentioned across several care plans instead of one overarching risk assessment being in place. Different actions would also be recorded for managing the same risks. We observed that at times people experienced anxiety and needed reassurance from staff. Although staff responded appropriately to people at these times, the recording of how to manage these situations was not always in place to ensure consistency.

There was often inconsistent or conflicting information in people’s care plans and monitoring records which made it hard to ascertain a person's most current needs.

Although quality assurance systems were in place to monitor the running of the home, these had not picked up all of the shortfalls identified at this inspection in order to address and take the necessary action.

Staff were not given opportunities to meet the requirements of their role. Staff had not always been given the opportunity to renew their training within the provider set timescales to ensure they maintained their skills and knowledge. We saw that medicines training had expired for four staff and not been renewed. We observed one of these staff continuing to administer medicines during our inspection.

The home had not always obtained the appropriate consent before taking decisions on behalf of people to ensure care was given in line with their preferences. One person had a sensor mat in place to alert staff when they moved around their bedroom but there was no consent to show their agreement or assessment of their capacity to take this decision.

People felt safe living at Kingston House and the comment form one person included, “I feel really safe being with other people in the home and living in a nice area. If I need help I am confident the staff would respond as I have seen them respond to others if they needed help or medical support.” Staff had the knowledge and confidence to identify safeguarding of abuse concerns and knew to act on them to protect people.

We observed staff responding to people respectfully and engaging people in positive interactions including singing and chatting. One person told us “I like living here, we have things here we can do and look at.”

The registered manager promoted a positive culture and was a visible presence around the home supporting people and staff when needed. People and their relatives praised the management of the home.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

We looked at people's individual files which incorporated their personal profile, care plans and risk assessments and found they encompassed the safety and well-being of people who used the service. People told us that they knew how to raise a concern or complaint and felt confident in doing so. They said if they had any issues or concerns they could "talk to the

manager." There were policies and procedures in place providing guidance and all staff had received relevant training courses which were identified on the training schedule. Staff told us they were supported by management and that they had received regular training, supervision and appraisals.

We looked at the cleanliness and infection control procedures and the management of medicines and found the provider had adequate systems in place to ensure the safety of the people who used the service regarding the control of substances hazardous to health and the administration of medicines.

We observed the way staff helped people during the lunchtime meal. We saw staff speak to people at eye level and asked them to make a choice of dessert and drink. Staff used a gentle, but professional approach when they spoke to people. The care plans we read showed people's dietary needs, including diabetic, vegetarian and fortified diets were met.

On the day of the inspection malnutrition screening tool (MUST) training was being delivered to staff. This training was to help staff assess people at risk of weight loss. The records showed people's food and fluid intake was monitored where they had been assessed as being at risk of weight loss. Staff needed to ensure they were being consistent in how they recorded people's food and fluid intake.

The cook was taking steps to ensure people had a say about the meals served and sought their preferences about the way their meals were presented.