CQC report explained · a residential care home
What the CQC found at Kingston House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, December 2023
Requires Improvement; inspectors found kind care, but serious problems with medicines, risk checks, recruitment and management oversight.
The inspection was unannounced. Two inspectors visited on 13 October 2023 and carried out inspection activity until 24 October. They observed care, spoke with staff and management, reviewed care and medicine records, and spoke with a relative and health and social care professionals.
The home was rated Requires Improvement overall. Safe and well-led were also Requires Improvement. Caring was rated Good. Inspectors found people were treated kindly and respectfully, with enough staff on duty, but medicines were not always managed safely and some risks were not properly assessed or managed.
The home had not acted on problems found at the previous inspection. Audits, staff supervision and meetings were not taking place, and records were not always complete. The provider was in breach of Regulations 12, 17 and 18, and a warning notice was issued for Regulation 17.
Kind and respectful care
Inspectors saw friendly, compassionate support. People had caring relationships with staff, who respected their privacy, dignity and individual needs.
“People received kind and compassionate care from staff who protected and respected their privacy and dignity and understood and responded to their individual needs.” from the report
Enough staff on duty
Rotas showed there were enough staff to meet people's current needs. Inspectors also saw staff respond promptly when people asked for help.
“Rotas confirmed that sufficient staff were on duty at all times to meet people's current needs.” from the report
People involved in decisions
Staff used different ways to communicate with people who could not speak verbally. They supported people to make choices about their care and how they spent their day.
“Staff supported people to be as independent as possible with making decisions about their care and support and how they planned their day.” from the report
Working with professionals
The home worked with health and social care professionals and made appropriate referrals when people's needs or conditions changed.
“The service worked collaboratively with professionals and commissioners to ensure people's needs were met.” from the report
Missed medicine
seriousMedicine records were incomplete and did not match the stock held. A review found that one person had missed a medicine for 10 days, which had not been identified before the inspection.
“This review found a person had 'missed' their medication for 10 days.” from the report
Risks not properly managed
seriousSome identified risks, including choking and recurring infections, did not have risk assessments explaining how staff should keep people safe. Fire drills and safety checks for utilities were also inadequate.
“Therefore, staff lacked necessary guidance on how to protect people from identified risks.” from the report
Weak recruitment checks
seriousInspectors reviewed two new staff files and found that relevant checks had not been completed, including references. This meant there was no assurance that staff were safe to work with vulnerable people.
“Both showed that relevant recruitment checks had not been obtained, for example references had not been gained.” from the report
Poor management oversight
seriousThe provider had not put effective systems in place to monitor quality and safety. Audits, staff supervision and formal feedback opportunities were missing, despite similar concerns at the previous inspection.
“The provider had failed to establish satisfactory governance arrangements.” from the report
No recent fire drill
needs fixingStaff had not completed a fire drill since July 2022. Inspectors said this created a risk that staff would not know how to keep people safe during a fire.
“Staff had not competed a fire drill since 27 July 2022.” from the report
- 01What has changed to make sure medicines are recorded accurately and no doses are missed?
- 02How are choking, infection and other individual risks now assessed and explained to staff?
- 03Have all recruitment checks, including references, been completed for current staff?
- 04What regular audits, staff meetings and supervision now take place, and how are problems followed up?
- 05When was the most recent fire drill, and how are staff prepared to evacuate people safely?
This inspection reviewed Safe, Caring and Well-led; Effective and Responsive were not rated, and the report says the Safe and Well-led ratings remained Requires Improvement from the previous inspection. This explanation was written from the published report of 14 December 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, October 2022
Rated Requires Improvement; inspectors found recent improvements in staffing, medicines and care, but serious weaknesses in records, oversight and leadership.
This was a focused inspection after concerns about the culture, staffing and management. One inspector visited unannounced on 13 September 2022 and returned on 20 September to meet the new manager. They observed care, checked records and spoke with staff, relatives and health professionals.
The home was rated Requires Improvement overall. Safe and Well-led were also Requires Improvement. Responsive remained Good. Inspectors found that people were now supported by enough staff, received medicines safely and had more up-to-date care plans. People were treated with dignity, supported to make choices and helped to take part in activities and maintain relationships.
There were important weaknesses. Recruitment checks were not always recorded, care and risk records had not been updated quickly enough, and there were not enough audits or meeting records to show that safety and quality were being managed properly. Staff did not always have the skills or guidance to respond appropriately in risky situations.
The report says the provider breached Regulation 17 on good governance. The home had a new acting manager and deputy manager, and inspectors saw signs of improvement, but the changes were not yet fully established.
Safer medicines
Inspectors found that medicines were being given safely and in line with people's health needs and prescriptions. Staff had specialist training for rescue medicines.
“With the new management in place, people received their medicines safely and in accordance with their health needs and the prescriber's instructions.” from the report
Respectful support
People were treated with dignity. Staff sought consent before providing personal care and supported people to make choices about their day.
“Staff worked within the principles of the MCA and sought people's consent before providing them with personal care and assistance.” from the report
Activities and relationships
People were supported to take part in activities inside and outside the home. The home also helped people visit relatives in the community or at their relatives' homes.
“People were supported to maintain relationships that were important to them.” from the report
Improving leadership
The new acting manager and deputy manager were taking action to improve the culture and rebuild relationships with health and social care professionals. Relatives and staff were positive about the changes.
“Relatives and staff were positive about their leadership and believed "Things will get done now.” from the report
Weak oversight and records
seriousThe provider did not have strong enough systems to identify problems, analyse patterns or track improvements. Care records, risk assessments, meeting records and staff support records were incomplete or inconsistent.
“The provider failed to ensure systems were in place or robust enough to demonstrate safety was effectively managed.” from the report
Recruitment checks not recorded
needs fixingAlthough the provider had a recruitment process, records did not always show that suitable checks had been completed before staff supported people.
“Staff records were not able to confirm that appropriate checks were undertaken before they supported people in the service.” from the report
Staff guidance in risky situations
needs fixingInspectors found that staff did not always have the skills or guidance needed to respond appropriately when situations became risky.
“Staff did not always have the skills or guidance to respond appropriately in risky situations.” from the report
- 01What actions are in the provider's plan to address the Regulation 17 breach, and when will each action be completed?
- 02How are you checking that all recruitment files contain the required references, interview records and other checks?
- 03How often are care plans and risk assessments reviewed when a person's needs or behaviour changes?
- 04What training and guidance do staff now have for responding to risky situations?
- 05What audits and staff or managers' meetings are now taking place, and how are the results shared with relatives?
This was a focused inspection of Safe, Responsive and Well-led; Effective and Caring were not inspected and their ratings were not newly assessed. This explanation was written from the published report of 20 October 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 Kingston House
5 rated inspections over 9 years: the service has slipped, from Good to Requires improvement.
- December 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2022Requires improvementSafe: Requires improvementWell-led: Requires improvement
- March 2021Inspected but not ratedSafe: Inspected but not rated
- June 2018Goodup from Requires improvementSafe: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2017Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2013
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- February 2011
Registered with the Care Quality Commission on 7 February 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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