CQC report explained · a residential care home
What the CQC found at Kingsway Clayton House Residential Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Medicines, staffing, infection control and incident management were found to be safe, although one person's falls-related care plan needed clearer recording and was addressed during the inspection.
- Effective?
- Good
- This question was not inspected during this focused visit.
- Caring?
- Good
- This question was not inspected during this focused visit.
- Responsive?
- Good
- This question was not inspected during this focused visit.
- Well-led?
- Requires improvement
- Governance had improved, but leadership arrangements were temporary and no person had been formally appointed to act on the provider's behalf. This resulted in a breach of Regulation 4.
What inspectors found, May 2022
Kingsway Clayton House Residential Care Home was rated Requires Improvement; safe care had improved, but legal responsibility and long-term leadership arrangements were not in place.
This was an unannounced focused inspection on 16 February 2022. The inspector looked only at Safe and Well-led. They spoke with three people, six staff and reviewed care, medicine, recruitment, training and management records.
Safe was rated Good. Inspectors found improvements in safeguarding, medicines, staffing and the way incidents were managed. People had individual care plans, were supported to access healthcare and could take part in activities or spend time where they wished.
Well-led was rated Requires Improvement. The home had improved its checks and oversight since the previous inspection, but the arrangements were temporary. The provider was not able to oversee the regulated activities because of ill health, and no person had been formally appointed to act on the provider's behalf.
The overall rating remained Requires Improvement. The previous inspection rating, published on 15 December 2021, was also Requires Improvement. The home was no longer in breach of the earlier safeguarding, safe care and treatment, and governance regulations, but a new breach relating to provider responsibility was identified.
Improved safeguarding
The home had strengthened how it managed people's money and supported people when they became distressed. Staff had training and understood how to recognise and report abuse.
“The systems and processes in place to manage people's finances were robust and staff were all aware of and used the new processes effectively.” from the report
Safe medicines
Medicines were stored and given safely. Records included photographs, allergy information and guidance for medicines given when needed.
“People were supported with administration of their medicines in a safe way.” from the report
Enough trained staff
Inspectors found enough appropriately trained staff, including during recent COVID-19-related staff sickness. Recruitment checks had also been completed.
“People were supported by adequate numbers of staff who had received training for their roles.” from the report
Person-centred support
People had individual care plans and positive behaviour plans. Staff supported people to choose activities, spend time in different areas and personalise their rooms.
“The information in people's care plans was written in a person-centred way and the positive behaviour plans were being used effectively to support people's daily activities.” from the report
No formal long-term responsibility
seriousThe provider could not oversee regulated activities because of ill health. No person had been legally appointed to act for the provider, so lasting leadership arrangements were not yet secure.
“There were no arrangements for a person to legally act on the provider's behalf.” from the report
Some risk records needed updating
needs fixingThe deputy manager was reviewing risk assessments. One person had more falls linked to mobility needs, but the care plan did not clearly record the actions needed to keep the person safe.
“However, another person had an increase in falls due to their mobility needs and the actions taken to safely support the person were not clearly recorded in their care plan.” from the report
Some notifications were late
minorSeveral Deprivation of Liberty Safeguards notifications had not been sent when inspectors visited. The report says these were submitted after the inspection.
“They told us they had not sent in the statutory notifications for these but would address this as soon as possible.” from the report
- 01Who is now legally responsible for the service while the provider cannot oversee regulated activities, and when were these arrangements formalised?
- 02What is the timetable for completing and checking the remaining risk assessments?
- 03How is the home recording and reviewing support for people whose mobility or falls risk changes?
- 04What process is now in place to ensure all Deprivation of Liberty Safeguards notifications are sent on time?
- 05How will the home maintain safe staffing levels during staff sickness or another COVID-19 outbreak?
This was an unannounced focused inspection of Safe and Well-led only; the other key questions were not inspected and the overall rating used the existing ratings for those areas. This explanation was written from the published report of 12 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, December 2021
Rated Requires Improvement; inspectors found serious safeguarding and leadership failures, with the well-led rating Inadequate.
This was an unannounced inspection on 3 November 2021. Inspectors visited the home, spoke with staff and relatives, and reviewed care, medicines, recruitment and management records. The inspection was prompted partly by safeguarding concerns.
Inspectors found that people were not always protected from abuse or avoidable harm. Financial controls were weak, some restrictive and punitive approaches were used, risks were not always assessed properly, and incidents were not consistently recorded or reviewed.
There were enough staff, medicines were managed safely, and infection control arrangements were in place. However, the provider and manager did not have effective checks on the quality and safety of care. The overall rating fell from Good at the previous inspection to Requires Improvement, while well-led fell to Inadequate.
Staffing levels
Inspectors found enough staff to support people. Relatives also said staffing was sufficient, including for people going out into the community.
“People were supported by sufficient numbers of staff. People's relatives told us they felt there was enough staff to support their family members” from the report
Medicines
Medicines records contained clear instructions, medicines were stored safely, and regular audits were carried out.
“Medicines administration was safe. People had clear information in the medicines administration records (MARs).” from the report
Infection control
Inspectors were assured about the home's infection prevention arrangements, including PPE, testing, cleaning and visits.
“We were assured that the provider was using PPE effectively and safely.” from the report
Community activities
People were supported to take part in activities they chose and to access the local community.
“Staff ensured people could access the community to undertake activities of their choice.” from the report
Safeguarding and restrictive practices
seriousPeople were not always protected from abuse. Inspectors found unnecessary physical restraint and punitive practices such as locking people out of bedrooms or withholding activities and belongings.
“People were not always protected from the risk of abuse. The systems and processes in place to manage people's finances were not robust.” from the report
Risks and incident learning
seriousIncidents were not consistently recorded, investigated or used to update risk assessments. This included a fall and serious health conditions affecting two people.
“The failure to review and learn from incidents exposes people to the risk of reoccurrence and consequent of harm.” from the report
Leadership and oversight
seriousThe provider did not have effective governance systems. Important risks, poor practices and financial control failures were not identified before the inspection.
“There was a lack of governance at the service from both provider and registered manager level.” from the report
Staff recruitment
needs fixingSome recruitment records were incomplete. Inspectors could not be assured that all staff had been properly checked as suitable.
“Safe recruitment practices were not always in place.” from the report
Financial controls
seriousThe home's finance policy was not followed. Transactions were not always witnessed by two staff and receipts were not kept, creating a risk of financial abuse.
“Specifically, transactions had not been witnessed by two staff and receipts of expenditure had not been kept.” from the report
- 01What has changed to prevent staff using punitive approaches, restraint or restricting access to bedrooms, belongings and activities?
- 02How are incidents now recorded, investigated and used to update people's risk assessments?
- 03How are people's money and spending now checked, witnessed and supported with receipts?
- 04What formal quality checks does the provider now carry out, and how are concerns reported and acted on?
- 05How does the home ensure restrictive practices are lawful, person-centred and properly considered under the Mental Capacity Act and DoLS process?
This was an unannounced inspection prompted partly by safeguarding concerns and the report gives ratings for Safe and Well-led only; it also reviewed infection control, records, staffing and medicines. This explanation was written from the published report of 16 December 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 Kingsway Clayton House Residential Care Home
5 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- May 2022Requires improvementcurrent ratingstayed Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Kingsway Clayton House Residential Care Home →
- December 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Inadequate
Read what inspectors found at Kingsway Clayton House Residential Care Home →
- December 2019Goodstayed GoodSafe: GoodWell-led: Good
- May 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2014
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 10 December 2010.
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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9 live-in carers within about an hour of Lincolnshire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
8 can care for a couple. 10 years' experience on average.
“Martin was more than a carer, he managed the home and became my uncle's best friend, enriching his life during his last few years.”
“Magda was always positive and proactive about trying new things to keep dad busy. She also introduced new ideas for keeping dad healthy.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.