CQC report explained · a nursing home
What the CQC found at Kingswood Court Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, June 2023
Rated Requires Improvement; inspectors found safer staffing and medicines, but gaps in care records and weak oversight remained.
This was an unannounced, focused inspection on 12 April 2023. Inspectors checked whether the home had improved after its previous inspection. They spoke with people, relatives and staff, and reviewed care records, medicines records, staffing files, safety checks and audits.
Staffing had improved. The home had recruited care and nursing staff, used agency staff only when needed, and increased staffing on some floors. Medicines were administered and recorded safely. Inspectors also saw improvements in risk management, infection control and how people were positioned for meals and comfort.
However, food, fluid and repositioning records had gaps. Some records did not show what people had eaten, drunk or when they had been repositioned. The home said these things had happened, but the records did not reliably show this. The system for checking records had not identified these problems.
The overall rating was Requires Improvement. Safe and well-led were both rated Requires Improvement. Two previous breaches had been met, but the home remained in breach of Regulation 17 about good governance.
Safer medicines
Medicines were given on time, actual administration times were recorded, and staff giving medicines had been assessed as competent.
“Medicines records showed that topical medicines were consistently recording that they had been applied.” from the report
Kind interactions
Inspectors saw staff supporting people in a friendly way. People and relatives also described staff as kind, although feedback about care was mixed.
“Staff interacted and supported people in a kind and friendly way.” from the report
Better risk management
People were more safely positioned for meals and were not spending long periods in wheelchairs. Call bells were observed to be answered promptly.
“People were no longer spending periods of time sitting in wheelchairs.” from the report
Incomplete care records
seriousFood, fluid and repositioning charts had gaps. This meant the home could not reliably show that people's needs had been met.
“Food, fluid, and repositioning charts continued to have gaps in recording.” from the report
Weak quality checks
seriousThe governance system had not identified obvious record-keeping problems. This was a continued breach of Regulation 17.
“The systems in place for monitoring the quality of the service were not always robust.” from the report
Mixed views about staff time
needs fixingSome people said staffing was better, but others said staff were rushed or that they had waited a long time for help.
“Mainly good but last week took an hour to get to the toilet one afternoon” from the report
- 01How are food, fluid and repositioning records completed and checked now?
- 02Have the charts been returned to each person's room, and how does this make recording easier for staff?
- 03What action has been taken to meet the continued breach of Regulation 17?
- 04How many care and nursing staff are on each floor during the day and night?
- 05How do you make sure staff have enough time to respond to call bells and support people without rushing?
This was a focused inspection of Safe and Well-led only; the other key question ratings carried over from the previous inspection. This explanation was written from the published report of 9 June 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, September 2022
Kingswood Court Care Home was rated Requires Improvement; inspectors found staffing, medicines, infection control and management problems.
This was an unannounced focused inspection on 10 August 2022. Inspectors looked at Safe and Well-led because concerns had been raised about staffing. They spoke with people, visitors and staff, and checked care records, rotas, medicines records, incident records and audits.
There were not enough staff at times. People experienced delays with personal care, meals and moving around the home. Some people spent long periods in wheelchairs or in their bedrooms with little interaction. Inspectors also found risks involving medicines, food and drink, call bells, positioning and infection control.
The home had a new manager and an action plan. The provider said staffing would be increased and activities would be expanded. However, inspectors found that existing checks had not identified important problems. The overall rating fell from Good at the previous inspection to Requires Improvement.
Safety checks
The home had robust checks for the building and equipment, including fire, gas, electrical systems, the lift and equipment used to support people.
“Robust systems were in place to ensure the home was safe such as legionella, fire, electrical and gas checks.” from the report
Incident reporting
Staff understood how to report accidents and incidents. Records included what had happened and what action had been taken.
“Written accident and incident documentation detailed what had happened and, what action had been taken.” from the report
New improvement plan
The new manager had set out actions covering staffing, pressure area wounds, weight management, inductions and staff supervision, with timescales.
“The new manager had developed an action plan to make improvements to the home.” from the report
Some positive care feedback
Feedback was mixed, but some people said staff were friendly and that they were satisfied. The home had also received compliments.
“The staff are nice friendly people. They do their best” from the report
Staffing shortages
seriousThere were delays with personal care, meals and moving people between areas. Some people remained in wheelchairs for prolonged periods, and inspectors found this could increase the risk of harm.
“People were not being supported by sufficient numbers of staff.” from the report
Medicines were delayed or poorly recorded
seriousSome medicines were given late and staff did not always record the actual time they were given. A prescribed cream had no recorded application since December 2021.
“There were delays in people receiving their medicines in a timely manner.” from the report
Risks with food and drink
seriousFluid records were not consistently totalled or linked to recommended intake. One person at risk of weight loss did not have a food and fluid chart to monitor their intake.
“We could not be assured people at risk were eating and drinking enough.” from the report
Infection control shortfalls
needs fixingSome staff were not wearing masks as required. PPE was stored on dirty linen trolleys, and some bathrooms were difficult to clean.
“There was a lack of PPE stations and masks, gloves and aprons were being stored on soiled linen trolleys.” from the report
Care was not always person centred
needs fixingSome people were left in bedrooms with little interaction, and their preferences about personal care and where they spent time were not always followed.
“We could not be assured that everyone in the home experienced person-centred care where choices and preferences were respected.” from the report
Weak quality monitoring
seriousThe home's audits and governance systems had not identified the problems found during the inspection. This meant the provider could not show that care and safety were being monitored effectively.
“Systems were not robust enough to demonstrate there were effective systems to monitor the service by the provider or the manager.” from the report
- 01How many staff are now working on each shift, and how do you check that this is enough for the current residents' needs?
- 02How do you make sure medicines are given on time and that the exact administration times are recorded?
- 03How are food and fluid intake monitored for people at risk of weight loss, dehydration or choking?
- 04What has changed since the inspection to keep PPE separate from dirty linen and ensure staff follow mask guidance?
- 05How are residents' personal preferences, activities and one-to-one time being recorded and delivered now?
This was a focused inspection of Safe and Well-led only; the other ratings carried over from the previous inspection and were used to calculate the overall rating. This explanation was written from the published report of 15 September 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 Kingswood Court Care Home
6 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- June 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2022Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- January 2022GoodSafe: GoodWell-led: Good
- May 2021Inspected but not ratedSafe: GoodEffective: GoodWell-led: Good
- December 2020Inspected but not ratedSafe: Inspected but not rated
- July 2018Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2017Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2016Inspected but not ratedSafe: Requires improvementEffective: Requires improvementResponsive: Requires improvement
- October 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2020
Registered with the Care Quality Commission on 7 April 2020.
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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