CQC report explained · a residential care home
What the CQC found at Kingsway Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- The home assessed people's individual risks, had enough staff and managed infection control and medicines in most respects. However, it did not recognise or report some physical altercations as safeguarding concerns, and three medicines had not been discarded within the recommended time.
- Effective?
- Good
- People's needs were assessed before they moved in, care records were updated and staff had suitable training and knowledge. Staff supported people's health, nutrition, communication, choices and access to health professionals.
- Caring?
- Good
- Staff were kind, respectful and compassionate. People were offered choices, supported to express their views and helped to maintain their dignity and independence, although some relatives could not recall being involved in care reviews.
- Responsive?
- Good
- Care plans included people's preferences, communication needs and life histories. People were supported with activities, outings and relationships, and complaints were investigated and acted on.
- Well-led?
- Requires improvement
- The home had a clear management structure and a positive culture, and staff felt supported. However, audits did not identify missed safeguarding and CQC notifications or the medicines that needed to be discarded.
What inspectors found, April 2023
Kingsway Care Home is rated Requires Improvement; inspectors found kind, personalised care but failures to report safeguarding incidents and weaknesses in oversight.
Inspectors visited on 7 and 9 February 2023. The first visit was unannounced and there was an announced return on the second day. They spoke with people, relatives, staff and managers, and checked care plans, staff files, medicines and management records.
The home supported 9 people at the time of inspection, all of whom had learning disabilities or were autistic. Inspectors found good care in the Effective, Caring and Responsive areas. Staff supported people's choices, dignity, communication, health, activities and independence.
Safety and management needed improvement. The home had not recognised that some physical altercations between people should have been reported as safeguarding concerns to the local authority and the CQC. Some medicines were also kept beyond the recommended time after opening.
The overall rating remains Requires Improvement, as it was at the previous inspection in August 2019. Effective, Caring and Responsive improved from Requires Improvement to Good, but Safe and Well-led remained Requires Improvement.
Kind and respectful staff
Inspectors observed positive interactions. People and relatives spoke positively about the staff and the support they received.
“People received care and support from staff that was kind, caring and compassionate.” from the report
Personalised support
Care plans reflected people's likes, dislikes, communication needs and preferences. Staff supported people to make choices and stay as independent as possible.
“People were supported to express their needs and be involved as fully as possible in their care.” from the report
Activities and community access
People took part in chosen interests, outings and activities. The garden and sensory room also gave people places to relax and spend time.
“People were supported to participate in their chosen social and leisure interests on a regular basis.” from the report
Good health support
Staff worked with health professionals and knew what to do when people became unwell or needed emergency help.
“There were processes in place to monitor people's health.” from the report
Safeguarding incidents were not reported
seriousThe provider investigated incidents and took action, but did not recognise that some physical altercations needed to be reported to the local authority. This created a risk that outside professionals would miss opportunities to review people's support.
“In 6 months there had been 34 incidents of which 18 had involved physical altercations between people.” from the report
Missed management checks
seriousAudits did not identify that safeguarding incidents had not been reported to the local authority or the CQC. This was linked to a breach of regulations.
“Regular audits had been completed to monitor and maintain a quality service. However, the audits had failed to identify incidents between people had not been reported to the local authority or the CQC.” from the report
Medicines past their opening period
needs fixingTwo homely medicines and one cream had not been discarded within the recommended time after opening. The manager disposed of them immediately.
“2 homely medicines and 1 cream had not been discarded within the recommended time frame after they had been first opened.” from the report
Some families were not involved in reviews
minorCare plans had improved, but some relatives could not remember being asked to take part in care plan reviews or development.
“There could be more still done to involve people in the review and development of care plans and reviews.” from the report
- 01What advanced safeguarding training have managers and care staff completed since the inspection?
- 02How are physical altercations and other incidents now assessed and reported to the local authority and the CQC?
- 03What checks now make sure medicines and creams are discarded within the recommended time after opening?
- 04How will you involve my relative and our family in care plan reviews?
- 05What progress has been made since the CQC said it would monitor improvements with the local authority?
This inspection assessed all five CQC questions and included infection prevention and control checks; it followed a previous comprehensive inspection whose rating was published in August 2019. This explanation was written from the published report of 12 April 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 2019
Rated Requires Improvement; improvements ended Special Measures, but inspectors found care plans, choice and quality checks still needed work.
This was an unannounced follow-up inspection on 13 and 17 June 2019. Inspectors spoke with people, relatives, staff and an advocate. They reviewed care records, medicine records, staff files and management records.
The home had improved since its previous Inadequate rating. Fire safety, risk assessments, medicines and safeguarding arrangements were better. People generally said they felt safe and received kind support. However, people were not always involved enough in care planning, and some choices about daily routines were unclear.
All five areas were rated Requires Improvement. This means the home was not consistently meeting the expected standard, although inspectors found enough improvement for the home to leave Special Measures and no longer be in breach of the regulations identified at the previous inspection.
Improved safety
Fire safety arrangements and risk assessments had improved since the previous inspection. Staff could explain how they would reduce known risks.
“The fire safety arrangements in the home had now improved and people were now safer as a result.” from the report
Medicines management
Inspectors found medicines were stored safely and administration records were accurate. The home had acted on recommendations from a pharmacist.
“People's medication administration records (MARS) were accurately completed and we saw medicines were stored safely.” from the report
Activities and community links
People took part in activities they enjoyed, went into the community and kept in touch with family and friends.
“People and their relatives told us they were able to maintain links with family and friends when they wished.” from the report
Action after the previous inspection
The provider had made enough progress to address the previous breaches. The home was no longer rated Inadequate or in Special Measures.
“During this inspection the provider demonstrated that improvements have been made.” from the report
Limited involvement in care plans
needs fixingSome people and relatives said they had not seen care plans or attended a care review. The home needed a formal process that invited people and appropriate others to discuss care.
“People said they talked to staff about what they wanted but told us when asked about their care plans, "I haven't seen a care plan" and "I don't know".” from the report
Training updates
minorSome core staff training was out of date, although updates had been planned.
“While staff had received training, records showed some core training needed updating.” from the report
Complaints information
needs fixingPeople were unsure how to complain. The complaints procedure was not easy for some people to understand and did not give fully correct information about further steps.
“The complaints procedure, whilst it was visible in the home it was not in a format that would be easy for some people to comprehend, such as, in pictorial format.” from the report
Quality monitoring records
needs fixingAudits had helped drive improvements, but some findings were recorded on Post-it notes rather than dedicated audit forms. This could mean learning or required actions were lost.
“There was a danger learning may be misplaced and identified improvements not made.” from the report
- 01How are people now involved in writing and formally reviewing their care plans?
- 02How do you make sure each person can choose their daily routine, including when they go to bed?
- 03Which staff training was out of date, and has all required training now been completed?
- 04How is the complaints procedure provided in an accessible format for people who need pictorial or simpler information?
- 05How are audits and actions now recorded so that learning is not lost and improvements can be checked over time?
This was an unannounced follow-up inspection covering all five key questions after the previous Inadequate inspection and Special Measures period. This explanation was written from the published report of 31 August 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 Kingsway Care Home
3 rated inspections over 4 years: the service has improved, from Inadequate to Requires improvement.
- April 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2019Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- April 2019InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- September 2017
Registered with the Care Quality Commission on 22 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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