CQC report explained · a nursing home
What the CQC found at Kingsbury Court
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, September 2022
Rated Requires Improvement; inspectors found serious staffing and management problems, although medicines were handled safely and improvements had begun.
This was an unannounced focused inspection on 16 August 2022. Inspectors looked at Safe and Well-led because of concerns about staffing and risk management. They spoke with people, relatives and staff, and checked care plans, medicines records, recruitment checks and management records.
The home did not always have enough suitably skilled staff in the right places. People sometimes waited for help, were left in bed because staff could not safely support them to get up, and did not always receive meaningful interaction or basic care promptly. Inspectors said this created risks including falls, worsening health and social isolation.
A new manager had started making improvements, including better clinical meetings, communication, audits and links with health and social care professionals. However, these changes were not yet fully in place. The home was rated Requires Improvement overall, with Safe and Well-led also rated Requires Improvement. The other question ratings were carried over from the previous inspection.
Safe medicines support
Inspectors found that people received medicines safely. Staff who had been assessed as competent followed good practice, and medicines were stored and audited appropriately.
“We observed staff who were assessed as competent to support people with their medicines did so in line with good practice requirements.” from the report
People generally felt safe
People and relatives generally said they felt safe in the home. Staff knew how to report concerns about abuse or neglect.
“People and their relatives told us they felt safe in the home.” from the report
Positive management changes
The new manager had improved oversight of people's care, introduced weekly clinical meetings and strengthened communication with staff and outside professionals.
“The new manager improved how people's care was overseen.” from the report
Not enough staff
seriousStaffing levels and deployment did not always meet people's needs. Some people waited for help, and four people were not supported to get out of bed because staff could not safely monitor them.
“There were insufficient numbers of suitably qualified, competent, skilled and experienced staff and they were not always effectively deployed in order to provide people with holistic, good quality and safe support and care.” from the report
Risk of isolation and delayed care
needs fixingSome people spent much of the day in bed without meaningful interaction. Others waited for continence care, routine morning care, tea or snacks.
“Some people spent the whole day in bed with no evidence of any interaction or meaningful engagement offered by staff apart from basic care and daily support.” from the report
Weak governance
seriousManagement systems had not consistently found or dealt with problems in daily records, risk assessments and referrals to healthcare professionals. Inspectors said people were at increased risk of receiving inconsistent care.
“The provider had failed to ensure consistent and effective governance of the service before the new manager had started.” from the report
Infection risk assessments
needs fixingIndividual infection risks were not always assessed robustly. The provider completed an individual risk assessment on the inspection day after inspectors raised the issue.
“Where people had an infection, this was not always robustly risk assessed around their individual circumstances.” from the report
- 01How many suitably skilled staff will be deployed on each floor, including at busy times such as breakfast and dinner?
- 02How will you make sure people are supported to get out of bed and mobilise safely when they want or need to?
- 03What activities and daily interaction are available for people who spend time in bed?
- 04How are care records, risk assessments and healthcare referrals checked and followed up now?
- 05What progress has been made on the staffing review and the action plan requested by the CQC?
This was a focused inspection of Safe and Well-led only; the other ratings carried over from the previous inspection. This explanation was written from the published report of 30 September 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, August 2021
Rated Good; inspectors found safe care and strong management, although the home could be busy at some points of the day.
This was an unannounced focused inspection on 19 July 2021. Two inspectors spoke with people, relatives and staff. They reviewed care records, medicines records, staff files and management records, and checked infection control arrangements.
The inspectors rated Safe and Well-led as Good. They found that people received safe care, staff understood people's individual risks and needs, medicines were managed safely, and infection control arrangements were suitable.
The home had enough staff to provide safe care, although staff said some days were busier. Management reviewed staffing levels, staff skills and recruitment needs. The overall rating remained Good.
The other three questions were not inspected during this visit. Their previous ratings were used for the overall rating.
Safe care
Staff knew people's risks and individual needs. Inspectors saw staff providing suitable support with mobility, distress and other health needs.
“People received safe care and support and staff knew their individual needs.” from the report
Medicines and infection control
Medicines were checked and recorded safely. Inspectors were assured about the arrangements for preventing and managing infections, including COVID-19.
“People were protected from spread of infections, including COVID-19 and received safe support with their medicines.” from the report
Learning from incidents
The home reviewed accidents and incidents, updated risk assessments and care plans, and took action to reduce further risks.
“The registered manager ensured all incidents and accidents were reviewed for lessons learned.” from the report
Positive management
The registered manager had improved the way the home was run. Audits, improvement plans and regular meetings were used to monitor care and safety.
“The registered manager had good oversight of the quality and safety of the service.” from the report
Respecting choice
Inspectors found changes that supported people's dignity, independence and choices, including making the dining room more accessible.
“The management created a culture of empowerment and continued improvement.” from the report
Busy periods
minorThe home had enough staff overall, but staff said some days were busier. Ask how quickly support is provided at the busiest times.
“There were enough staff on duty to provide safe care and support, although the home was busy at some points of the day.” from the report
- 01How do you make sure there are enough staff during the busiest points of the day?
- 02How do you check that care plans and risk assessments change promptly when a person's needs change?
- 03What infection control and visiting arrangements are currently in place?
- 04How are relatives told about accidents, falls or changes in medicines?
- 05What improvements have been made to mealtimes, menus and people's individual diets?
This was a focused inspection of Safe and Well-led only; the other three ratings were carried over from the previous comprehensive inspection. This explanation was written from the published report of 7 August 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Kingsbury Court
6 rated inspections over 6 years: the service has held its Requires improvement rating throughout.
- September 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2021Goodstayed GoodSafe: GoodWell-led: Good
- January 2021Goodstayed GoodSafe: GoodWell-led: Requires improvement
- December 2019Goodstayed GoodSafe: Requires improvementWell-led: Good
- May 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- April 2015
Registered with the Care Quality Commission on 2 April 2015.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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77 live-in carers within about an hour of Surrey
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Most charge £980 to £1,250 a week. 66 can care for a couple. 11 years' experience on average.
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