CQC report explained · a residential care home
What the CQC found at Kingsmount Residential Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, March 2020
Rated Good; inspectors found safe, kind and responsive care, but the home’s leadership and quality checks still required improvement.
This was an unannounced inspection over two days. The inspector spoke with people living in the home, visitors and staff. They also observed care and checked care plans, medicines, staff records and management systems.
The overall rating was Good. Safe, Effective, Caring and Responsive were all rated Good. People said they felt safe and were treated kindly. Inspectors found medicines were managed safely, staff were trained, and people received help with food, health needs, activities and communication.
Well-led was rated Requires Improvement. The home had improved since the previous inspection and was no longer breaching regulations. However, some care plans were not detailed enough, accident and incident information was not analysed for lessons, and quality checks were still being put into practice.
Safe medicines and risk management
Inspectors saw medicines being given safely and found that risks such as falls, malnutrition and pressure damage were assessed and reviewed.
“Medicines were managed safely. We observed staff administer people's medicines safely and according to their needs.” from the report
Kind and respectful care
People said staff were kind and caring. Inspectors observed positive interactions and found that staff knew people well.
“There was a relaxed and friendly atmosphere in the home and we observed many positive caring interactions between staff and people.” from the report
Activities and relationships
The home offered individual and group activities based on people's interests. People were supported to keep in touch with family and friends.
“The activities co-ordinator was passionate about stimulating people in a person-centred way.” from the report
Improvement since the last inspection
The provider had acted on the previous inspection findings. The earlier breaches of regulations had been resolved by this inspection.
“The provider had made improvements since our last inspection and were no longer in breach of regulations.” from the report
Quality checks were not fully established
needs fixingThe home was still putting its audit and monitoring programme into practice. It needed to demonstrate that improvements were sustained, including in person-centred care and incident review.
“A programme of audits and checks were in the process of being implemented and embedded into their practice.” from the report
Accidents were not analysed for lessons
needs fixingAccidents and incidents were recorded and investigated, but the records were not analysed to identify what could be learned and help prevent repeat events.
“Although this information was reviewed by the registered manager, the accident or incident records were not analysed to consider any lessons which could be learned from incidents and accidents to avoid the risk of it happening again.” from the report
Some care plans lacked detail
needs fixingSome plans did not explain people's preferences or the precise support they needed. This could mean care was not always delivered in the person's preferred way.
“However, we saw some care plans were not as detailed or person-centred as others to ensure people's preferences were reflected.” from the report
- 01How will you make sure the new computerised care plans include each person's preferences and the exact support they need?
- 02How do you review accidents and incidents, and how do you make sure lessons are acted on?
- 03Which quality audits are now complete, and how do you check that improvements remain in place?
- 04Have all staff appraisals now been completed, and how often are staff supervision and training reviewed?
- 05How do you check that staffing levels remain sufficient when staff are busy or people’s needs change?
This was an unannounced planned inspection covering all five CQC questions; the previous overall rating was Requires Improvement and the earlier regulatory breaches had been resolved. This explanation was written from the published report of 17 March 2020 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, February 2019
Rated Requires Improvement; inspectors found kind, person-centred care, but serious gaps in risk management, medicines records and quality checks.
Inspectors visited on 7 and 10 December 2018. The first visit was unannounced. They spoke with people, relatives, staff and health professionals, observed care, checked records, medicines, staff files, the building and management systems.
People were generally treated with kindness and respect. Care was tailored to people's needs, activities had improved since the previous inspection, and food, health support and complaints handling were rated Good.
However, some important safety records did not show that planned care had been given. Mattress settings were not always correct, repositioning and skin cream records had gaps, low fluid intake was not always acted on, and medicine stock checks found discrepancies.
The overall rating is Requires Improvement. Safe and well-led were rated Requires Improvement, while effective, caring and responsive were rated Good. The home had no registered manager at the inspection, although a new manager had started two days earlier.
Kind and respectful care
People and relatives spoke positively about staff. Inspectors saw warm, compassionate interactions and found that privacy, dignity and independence were respected.
“Staff supported people with kindness, respect and compassion.” from the report
Personalised support
Care plans recorded people's preferences, life experiences and support needs. Staff used this information to provide individual care and meaningful engagement.
“People received support that was tailored to them as individuals” from the report
Improved activities
The home had worked to improve one-to-one engagement and activities since the previous inspection. It employed an activities co-ordinator and offered individual and group activities.
“Since the last inspection the home had worked very hard to improve the provision of one to one engagement and activities to reduce the risk of social isolation.” from the report
Food and health support
People had a choice of good-quality food and drinks. Staff supported health appointments and made referrals to health professionals when needed.
“People benefitted from a full range and choice of good quality food and drinks.” from the report
Clean environment
Inspectors found the home extremely clean and fresh-smelling. Staff used protective equipment and had infection-control training.
“Throughout the inspection we noted the home was extremely clean and smelled fresh throughout.” from the report
Pressure care records and equipment
seriousThree pressure mattresses were not set correctly for people's weights. Records also showed gaps in repositioning and missed applications of prescribed skin cream, which could increase the risk of skin damage.
“Records showed the person's position was not being changed as required and stated in their care plan.” from the report
Medicines stock discrepancies
seriousThe administration records had no missing signatures, but checks of five medicines found stock discrepancies in three. This could mean medicines were signed for but not given.
“This may indicate that medicines had been signed for but not given, as they remained in the blister pack.” from the report
Weak quality checks
seriousManagement audits did not identify the safety and record-keeping problems found during the inspection. This affected the well-led rating.
“The provider had systems in place to monitor the quality and safety of the home; however, these were not always robust nor effective” from the report
Individual staff appraisals
minorThree appraisal forms were identical rather than tailored to the staff members. Inspectors recommended that appraisals should be individual and discuss development needs.
“We recommend the provider ensures that all staff have the opportunity to benefit from regular appraisal tailored to the individual staff member” from the report
- 01What has been done to make sure pressure mattresses are set correctly for each person's weight, and who checks and records this every day?
- 02How do you now check that repositioning schedules and prescribed skin creams have been completed?
- 03How are medicine stock levels checked, and what happens if the records do not match the medicines remaining?
- 04How do managers identify and respond when someone consistently drinks less than their target amount?
- 05Has the manager's application to become the registered manager been submitted, and what changes have been made to the quality checks since the inspection?
This was a planned inspection of the overall service, with the first day unannounced; inspectors looked at all five quality questions and the previous ratings were changed where stated. This explanation was written from the published report of 20 February 2019 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 Kingsmount Residential Home
3 rated inspections over 4 years: the service has held its Good rating throughout.
- March 2020Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2019Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- January 2014
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 7 January 2011.
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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