CQC report explained · a nursing home
What the CQC found at Kingsthorpe View Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, September 2023
Kingsthorpe View Care Home is rated Requires Improvement, with unsafe practice and weak oversight still found, but it is no longer in Special Measures.
This was an unannounced focused inspection on 6 and 7 June 2023. Inspectors observed care, spoke with people, relatives and staff, and checked care records, medicines records, staff files and management records.
The overall rating improved from Inadequate to Requires Improvement, and the home left Special Measures. However, inspectors still found people at risk from problems with medicines, cleanliness, staff training and the management of risks and incidents.
Inspectors found that staff were generally kind and understood people's needs. Care plans, falls management and support with medicines had improved. But quality checks were not reliable enough to find and correct important problems.
The Safe, Responsive and Well-led ratings were Requires Improvement. This inspection did not cover the Effective and Caring key questions, so those ratings were not reassessed in this report.
Kind and respectful staff
People and relatives described staff as understanding, patient and kind. Relatives also said staff treated people with respect and allowed them to be themselves.
“Relatives and people told us that staff were understanding, patient and kind, and they gave positive feedback about the improving culture of the service and the management team.” from the report
Clearer risk plans
Care plans and risk assessments gave staff useful guidance. Inspectors saw appropriate equipment, supervision and guidance for people at risk of falls or behaviour-related harm.
“We found the care plans and risk assessments we reviewed gave clear guidance for staff on how to support people effectively.” from the report
Safer medicines administration
Inspectors found that ordinary oral medicines were administered and disposed of safely. Staff handling medicines had recent training and competency checks.
“Medicines were administered and disposed of safely. Staff involved in handling medicines had received training and recent competency checks around medicines.” from the report
Improved staffing levels
Staffing levels were based on people's needs, and people were supported by enough staff during the inspection. Recruitment checks were also in place.
“Staffing levels were set according to people's dependency needs to ensure that people were supported safely.” from the report
Personalised care planning
Care plans included people's interests, life histories, choices and end of life wishes. Relatives were involved in care reviews.
“People received person-centred care. We saw that people's interests and life histories had been explored within their care plans.” from the report
Medicine storage and covert medicines
seriousPrescribed creams were left in bedrooms with unreadable labels, creating a risk of them being used by the wrong person or swallowed. Some records authorising covert medicines were also missing.
“Prescribed creams for people containing medicine were left in their bedrooms. The labels were not readable and the risk of these being applied to the wrong people or a person ingesting these was high.” from the report
Cleanliness and infection risks
seriousSome bedrooms and other areas were not cleaned properly. Soiled laundry was stored with clean laundry, and audits had not identified these problems.
“Some of the bedrooms used by people were not cleaned effectively. We found areas of the service where soiled laundry had been left with clean laundry which presented a risk of cross contamination.” from the report
Staff training gaps
needs fixingNot all staff had training in areas needed for people's health and wellbeing, including falls, diabetes, behaviour support and palliative care.
“The registered manager had failed to ensure staff had received training in specific areas to enable them to effectively support people's health and wellbeing.” from the report
Weak quality checks
seriousManagement audits did not consistently find or fix problems with infection control, medicines, daily records, the environment or staff training. The provider remained in breach of Regulation 17.
“Provider audits in place had not identified or addressed some of the issues we found during inspection.” from the report
Limited activities and outdoor access
needs fixingMost relatives were negative about activities, interests and community involvement. Several relatives were concerned that people could not use the outdoor space.
“Feedback from relatives regarding activity and occupation for people was largely negative.” from the report
- 01What has been done to make sure prescribed creams are labelled clearly and stored safely?
- 02What authorisations and records are now in place for any medicines given covertly?
- 03Which staff still need training in falls, diabetes, behaviour support and palliative care, and when will this be completed?
- 04How are cleanliness checks now audited, particularly for bedrooms, laundry and the communal assisted bath?
- 05What is the timetable for improving the outdoor space and increasing activities or community involvement?
This was a focused inspection of Safe, Responsive and Well-led; Effective and Caring were not inspected and their ratings were not reassessed in this report. This explanation was written from the published report of 6 September 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, January 2023
Rated Inadequate and placed in special measures; inspectors found people at risk of harm from unsafe care, staffing and management.
This was an unannounced comprehensive inspection in November 2022. Inspectors observed care, spoke with people, relatives and staff, and reviewed care, medicine, recruitment and management records.
The home was not safe. Inspectors found problems with risk assessments, falls, skin care, choking risks, medicines, infection control, fire safety and staffing levels. They also found that incidents were not properly investigated and lessons were not learned.
There were some positive interactions. People and relatives said staff were kind and caring, and inspectors saw people supported well during meals. However, the overall rating was Inadequate, with Safe and Well-led rated Inadequate and the other three areas rated Requires Improvement.
The home was placed in special measures. The CQC requested an action plan and said it would work with the provider and local authority to monitor progress and inspect again within six months unless the provider's registration was cancelled.
Kind staff
People and relatives generally spoke positively about staff, and inspectors observed staff speaking to people kindly.
“People and their relatives told us staff were kind and caring towards them.” from the report
Support at meals
Inspectors saw people who needed help with meals being supported in a caring and dignified way.
“We observed a positive dining experience on both days of inspection.” from the report
Safe recruitment checks
The records reviewed showed that staff had appropriate references and DBS checks before starting work.
“We found staff had been safely recruited with appropriate references and disclosure and barring service (DBS) checks in place prior to their appointment.” from the report
Working with health professionals
Staff worked with several outside professionals involved in people's care, although inspectors also found some referrals were not made promptly.
“Staff worked closely with other professionals who were involved with people's care.” from the report
People were at risk of harm
seriousRisk assessments and care plans did not always explain how to manage falls, skin damage, choking or behaviour risks. Staff did not always follow the guidance that was in place.
“People living in the service were not safe and were placed at risk of harm.” from the report
Unsafe medicines management
seriousSome staff had not had recent medicines competency checks. Medicines were administered without the relevant administration record being available, and creams were left in communal bathrooms.
“Medicines were not administered and disposed of safely.” from the report
Insufficient staffing
seriousThere were not enough staff deployed to meet people's needs safely. Staff said they were leaving people unattended and did not have enough time to complete care records.
“There were not enough staff deployed across the service to support people safely.” from the report
Fire and infection risks
seriousPersonal emergency evacuation plans were missing, some staff did not know how to evacuate people upstairs, and some areas and equipment were not clean enough.
“Some of the staff we spoke with did not have an understanding of the equipment in the service used to evacuate people in the event of a fire or emergency.” from the report
Consent and personal choice
seriousMental capacity assessments and best interest decisions were not always completed. People and relatives were not always involved in care planning or decisions such as room moves.
“MCA assessments were not always completed.” from the report
Weak management oversight
seriousAudits failed to identify several problems, including poor hygiene, fire safety issues, training gaps and weak falls management. The home was not learning effectively from incidents.
“Governance in the service was not always reliable and effective.” from the report
- 01What evidence can you show that staffing levels now match the needs of people who require two staff or constant supervision?
- 02How are medicines, including creams and covert medicines, now checked and administered safely?
- 03Have every person's risk assessments and care plans been updated for falls, choking, skin care and behaviour risks?
- 04What action has been completed to improve fire evacuation plans, staff training and the cleanliness of equipment and communal areas?
- 05How are people and relatives now involved in care reviews, consent decisions, end of life planning and complaints?
This was a comprehensive inspection covering all five key questions after concerns about end of life care, safeguarding, consent, tissue viability and falls management. This explanation was written from the published report of 17 January 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.
Every inspection of Kingsthorpe View Care Home
6 rated inspections over 5 years: the service has held its Requires improvement rating throughout.
- September 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- January 2023InadequateSafe: InadequateResponsive: Requires improvementWell-led: Inadequate
- March 2022Inspected but not ratedSafe: Inspected but not rated
- January 2022Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Inadequate
- May 2021Inadequatedown from Requires improvementSafe: InadequateWell-led: Inadequate
- September 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- May 2018Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2022
Registered with the Care Quality Commission on 21 February 2022.
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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