28 April 2022
During an inspection looking at part of the service
Kingswood Mount is a care home providing accommodation, personal and nursing care for up to 45 people; some of whom lived with dementia and physical disabilities. At the time of our inspection 36 people were living at the service.
People's experience of using this service and what we found
The home's environment was unclean and unsafe. Infection prevention and control practices were inadequate and did not protect people from the risk of infections.
Relatives told us that staff members had a kind and caring approach towards their family members; but described the staff team as overstretched and under stress.
Records used to monitor, and review people's care were not fully completed and kept up to date. We found many examples where sections of care records were incomplete and where people's care plans had not been updated to reflect changes in their needs.
There were systematic and widespread failings in the way the service was led and managed. The systems in place for monitoring the quality and safety of the service were not used effectively. They failed to identify and mitigate risk and bring about improvements to the service people received. Daily checks of the environment, aspects of people's care and staffing had not taken place as required.
Medicines were administered safely and there were enough staff who knew people well to provide support.
People were supported to access healthcare services, staff recognised changes in people's health, and sought professional advice appropriately. Staff were confident about how to raise concerns to safeguard people.
For more details, please see the full report which is on the Care Quality Commission website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (published 08 February 2019)
Why we inspected
The inspection was prompted in part due to concerns received about the safe care and treatment of people. A decision was made for us to inspect and examine those risks. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. Please see full details in the individual sections of this full report.
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.
Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.
The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection. For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Enforcement
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.
We have identified breaches in relation to safe care and treatment, infection prevention and control and good governance at this inspection.
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 for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.