CQC report explained · a residential care home
What the CQC found at Kingsdown House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found unsafe gaps in risk assessments, infection control, fire evacuation plans, incident recording and medicines management. One person received an out of date medicine repeatedly.
- Effective?
- Requires improvement
- Staff did not always have the training needed for people's specific support needs. Mental capacity and best-interest decisions were not always clearly assessed or recorded.
- Caring?
- Requires improvement
- Staff were warm, respectful and knew people well. However, the provider's systems did not consistently put people at the centre of care or support dignity and respect.
- Responsive?
- Requires improvement
- People had activities, communication support and personalised interests, but care plans were not always person centred or accurate. Information was not always provided in formats suited to people's communication needs.
- Well-led?
- Requires improvement
- Management oversight, auditing and action planning were not effective enough to identify and fix risks. Staff also reported poor communication, inadequate resources and pressure caused by staffing shortages.
What inspectors found, May 2022
Rated Requires Improvement in every area; inspectors found kind care but serious gaps in safety, staffing, records and management.
This was the first inspection of the newly registered home. It was unannounced and took place over five days in January and February 2022. Inspectors spoke with people living there, relatives and staff, observed care, and checked care, medicines, staffing and management records.
People appeared happy and staff knew them well. Inspectors saw warmth, respect, support for independence, choice about food and activities, and access to healthcare. However, care plans and risk assessments were not always individual or up to date.
There were important safety concerns. One person received an out of date medicine on repeated occasions. Staffing levels were not maintained, some people did not receive their planned one-to-one support, and staff said they were tired. The home also had gaps in infection control, fire evacuation planning and incident recording.
All five areas were rated Requires Improvement. This means the home was not consistently providing safe, effective, caring, responsive or well-led care, and there was an increased risk that people could be harmed.
Kind staff
Inspectors saw staff treating people warmly and respectfully. Staff knew people's preferences and what could make them anxious.
“People received kind and compassionate care from staff who were positive and enjoyed their work.” from the report
Support for independence
People were encouraged to make everyday choices and take part in cooking, cleaning, laundry, shopping and caring for the garden.
“People were supported to maintain their day to day independence.” from the report
Food and choice
People chose meals, snacks and when to eat. They were supported to help prepare and cook food where this was safe.
“People were involved in choosing their food, shopping, and planning their meals.” from the report
Access to healthcare
People had health action plans and hospital passports. Staff supported access to dentists, opticians, chiropodists and specialist health teams.
“People had access to the health care they needed, including preventative health.” from the report
Medicines errors
seriousOne person's antibiotic medicine had expired but continued to be given repeatedly. Staff had raised the issue with the GP but did not escalate it to make sure the medicine was safe.
“One person's antibiotic suspension had expired and was still being administered up to a week past its expiry date.” from the report
Risks not managed individually
seriousSome risk plans were copied between people and did not give the detailed guidance staff needed. Concerns included choking, continence care, behaviour support and fire evacuation.
“Risk management plans did not take into account people's individuality, so plans were the same for different people.” from the report
Not enough staff
seriousStaffing levels were below assessed needs. Some people did not receive their planned one-to-one support, and staff reported tiredness after working demanding shifts.
“We are short staffed and that is impacting on everyone. I myself feel very tired” from the report
Weak management checks
seriousAudits did not reliably identify problems or show who would fix them and when. The manager was not always aware of outstanding maintenance and safety actions.
“The failure to closely monitor the quality and safety of the service was a breach of regulation 17” from the report
Best-interest records
seriousThe home did not clearly record how some decisions were made for people who could not make those decisions themselves. Families or advocates were not always involved.
“A record was not kept to document how the decisions were made in the person's best interests.” from the report
- 01What has changed to stop anyone receiving out of date medicines, and how are prescriptions now checked?
- 02How many staff are now on each shift, and how do you make sure planned one-to-one support is provided?
- 03Have every person's risk assessments and fire evacuation plans been rewritten to reflect their individual needs?
- 04How are mental capacity and best-interest decisions recorded, and when are families or advocates involved?
- 05What repairs and furniture replacements identified in the report have now been completed?
This was an unannounced first inspection of the newly registered home, covering all five CQC questions; the previous provider's Good rating was published on 16 November 2018. This explanation was written from the published report of 10 May 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, July 2021
Inspected but not rated; inspectors found strong infection control arrangements, but identified one shortfall in staff carrying enough masks.
This was an announced, targeted inspection on 8 July 2021. It followed concerns about infection prevention and control. Inspectors looked at how the home prevented and managed infection, rather than carrying out a full inspection of all aspects of care.
Inspectors were assured that visitors were screened, tested and supported to visit safely. They also found plans for isolating people if needed, good supplies of protective equipment, regular COVID-19 testing, enhanced cleaning and a clean, uncluttered building.
There was one weakness. Staff supported people in the community without carrying enough masks to follow the guidance on changing masks every two hours. The registered manager dealt with this immediately and discussed it with all staff.
The home was inspected but not rated. The report does not provide an overall quality rating or ratings for the other areas of care.
Safe visiting
The home arranged visits in safe places and used health screening, hand sanitising, masks, temperature checks and tests to reduce infection risks.
“Visitors were asked health screening questions and to sanitise their hands-on arrival and wear face mask.” from the report
Testing and isolation plans
The home had plans to isolate people if required and accessed testing for people living there and staff.
“Plans were in place to isolate people with COVID-19 to minimise transmission if required.” from the report
Clean environment
Inspectors found the building clean and free from clutter, with enhanced cleaning practices and protective equipment available.
“The building was clean and free from clutter and there were enhanced cleaning practices.” from the report
Management response
The manager acted immediately when the mask shortfall was identified and discussed it with all staff.
“The registered manager had actioned this immediately with the staff concerned.” from the report
Masks during community trips
needs fixingStaff supported people in the community without an adequate supply of masks. This did not follow the guidance on changing masks every two hours, although the issue was dealt with immediately.
“staff supported people into the community without having adequate supply of masks with them, which did not adhere to the guidance on two hourly change of mask.” from the report
- 01What specific checks now make sure staff carry enough masks when supporting people in the community?
- 02How are staff reminded about the guidance on changing masks every two hours?
- 03What infection control arrangements are currently used for visits, including screening, testing and face coverings?
- 04What are the home's arrangements for isolating someone if they develop COVID-19?
- 05How often are people living at the home and staff tested for COVID-19?
This was an announced, targeted inspection of infection prevention and control measures only; the service was inspected but not rated and the other care areas were not assessed. This explanation was written from the published report of 29 July 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 Kingsdown House
3 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- May 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- July 2021Inspected but not ratedSafe: Inspected but not rated
- November 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2020
Registered with the Care Quality Commission on 21 September 2020.
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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