CQC report explained · a nursing home
What the CQC found at Kingsclear
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, February 2023
Rated Good overall; inspectors found safe and responsive care, but leadership needed to embed recent improvements.
This was an unannounced focused inspection. Inspectors visited on 25 January 2023 and reviewed records, medicines, staffing, complaints, accidents and infection control. They spoke with people living in the home, relatives, staff and healthcare professionals.
The home was rated Good for Safe and Responsive. Inspectors found that risks were assessed, medicines were managed safely, infection control was effective and people received personalised care. Relatives said communication and involvement in care reviews had improved.
The home was rated Requires Improvement for Well-led. Recent changes and extra support from senior leaders had improved the service, but inspectors said these changes needed to become established and remain effective over time.
The previous overall rating was Requires Improvement, published in August 2022, with breaches of regulations. At this inspection, the provider was no longer in breach and the overall rating improved to Good. Effective and Caring were not inspected in this report, so their previous ratings were carried forward.
Safer risk management
Risks linked to falls, pressure ulcers, eating and drinking were assessed. The home put measures in place, such as pressure-relieving equipment, repositioning plans and referrals to specialists.
“Assessments had been carried out to identify any potential risks to people, including risks associated with mobility, skin integrity, and eating and drinking.” from the report
Medicines
Medicines were stored, administered and audited safely. Staff were trained and checked as competent before administering medicines.
“The sample of medicines administration records (MARs) we checked was up-to-date and accurate.” from the report
Personalised care
Care plans included people's needs, preferences, life histories and interests. Relatives had more opportunities to contribute to care planning and reviews.
“The care plans we checked were individualised and contained guidance for staff about how people preferred their care to be provided.” from the report
Activities and relationships
People could take part in activities such as quizzes, films, exercise classes and coffee mornings. Staff also helped people stay socially connected.
“The home's activities programme included in-house events such as quizzes, crosswords, film screenings, exercise classes and coffee mornings.” from the report
Improved communication
Relatives said communication had improved and that their views were listened to. Staff also said they felt more able to raise concerns and suggest improvements.
“Input from the provider's senior leadership team had improved the culture within the home.” from the report
Leadership improvements not yet established
needs fixingThe home was rated Requires Improvement for Well-led. Inspectors wanted to see whether the recent changes would continue to support safe, good-quality care over time.
“These improvements needed to be embedded and to underpin working practices to ensure people's safety and their experience of care was sustained over time.” from the report
Response times
needs fixingSome people said staff did not always respond promptly enough when they needed help quickly, including help to use the toilet. The provider said it would deploy additional staff.
“Some people told us staff did not always respond promptly enough when they needed them quickly.” from the report
Incomplete care information
needs fixingOne person's records did not include a care plan for a specific health condition. The provider acted after the inspection and sent evidence that a plan had been developed.
“We found one person's records did not include a care plan for a specific health condition and discussed this with the provider at the end of the inspection.” from the report
Information for activity staff
minorA member of the wellbeing team said they did not always know which people should avoid alcohol or sweet foods at events. The provider agreed to give the team the information needed.
“They were unaware which people should avoid these.” from the report
- 01How are you checking that the recent leadership and quality improvements have been maintained since the inspection?
- 02How quickly do staff respond to call bells, particularly when someone needs help with the toilet or another urgent need?
- 03How do you check that every person's care plan covers all their health conditions and current risks?
- 04How are wellbeing staff told which people need to avoid particular foods or alcohol at activities and events?
- 05What were the previous ratings for Effective and Caring, which were not inspected during this visit?
This was a focused inspection of Safe, Responsive and Well-led; Effective and Caring were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 24 February 2023 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 2022
Kingsclear was rated Requires Improvement; inspectors found kind care and some improvements, but ongoing safety, medicines, infection control and management concerns.
This was an unannounced follow-up inspection on 28 April 2022. Inspectors spoke with people living in the home, relatives and staff. They observed care and checked care plans, medicines records, staff files and management records.
The home was rated Good for Effective and Caring. People were treated kindly, supported with dignity and offered choices. Food, health care, activities and some risk monitoring had improved.
The home was rated Requires Improvement for Safe, Responsive and Well-led. Inspectors found problems with monitoring weight loss, broken equipment, cleaning, medicines records and the way concerns and improvements were managed. The home had been rated Requires Improvement at the previous inspection and had held this rating for six consecutive inspections.
Kind and respectful care
People and relatives described staff as kind. Inspectors saw warm interactions and staff respecting privacy, dignity and personal choices.
“Interactions we observed between people and staff were warm and friendly.” from the report
Food and drink choices
People generally enjoyed the food and were offered choices. Staff understood dietary needs, allergies, intolerances and modified diets.
“People were shown the options to help them in making a choice and food which was modified such as pureed was presented well.” from the report
Activities and relationships
The home offered activities including singing, baking, games, exercise and entertainment. Staff also supported people to keep in touch with relatives.
“Improvements had been made to the activities provided in Windsor with people taking part in sing-a-longs, baking groups and games.” from the report
Improved safeguarding and incident review
Safeguarding concerns were reported to the local authority. Accidents and incidents were reviewed so action could be taken to reduce repeat events.
“Accidents and incidents were recorded and action taken to minimise the risk of them happening again.” from the report
Weight loss was not always monitored
seriousTwo people's weight monitoring was not reliable. Alternative ways to monitor one person who could not be weighed had not been used.
“Systems to monitor people's weight loss were not always robust.” from the report
Medicines records and administration
seriousSome medicine administration times were recorded inaccurately. A person receiving covert medicines was left without staff checking that the full dose had been taken.
“The failure to ensure safe medicines practices were in place was a continued breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Cleaning and infection control
seriousSluice rooms and cleaning areas were dirty and cluttered. Equipment was not always clean, creating an infection risk.
“There was a risk of infection due to areas of the home and equipment being unclean.” from the report
Management checks missed problems
seriousAudits and meetings did not identify several issues, including unsafe cleaning practices, poor cleanliness, weight monitoring and medicines recording.
“Quality assurance systems were not always effective in identifying concerns.” from the report
Communication and complaints
needs fixingRelatives and staff said communication and organisation were inconsistent. Requests could be delayed, and complaints were not always acknowledged or followed up clearly.
“Relatives told us they felt the lack of organisation led to delays in requests being actioned” from the report
- 01How are you now monitoring people's weight when they cannot be weighed in the usual way?
- 02What checks make sure medicines are given at the right time and recorded accurately?
- 03How do you check that sluice rooms, storage areas and equipment remain clean?
- 04What has changed to make sure broken equipment and other safety risks are repaired promptly?
- 05How will you keep relatives informed about care changes and confirm that complaints have been answered?
This was an unannounced follow-up inspection covering all five key questions and infection prevention and control, following action required at the previous inspection. This explanation was written from the published report of 26 August 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.
Every inspection of Kingsclear
7 rated inspections over 5 years: the service has improved, from Requires improvement to Good.
- February 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2022Requires improvementstayed Requires improvementSafe: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- December 2021Requires improvementSafe: Requires improvementWell-led: Inadequate
- November 2020Inspected but not ratedSafe: Inspected but not ratedResponsive: Inspected but not ratedWell-led: Inspected but not rated
- October 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- October 2018Requires improvementup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2018Inadequatedown from Requires improvementSafe: InadequateWell-led: Inadequate
- May 2018Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- September 2017
Registered with the Care Quality Commission on 25 September 2017.
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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