Kingsthorpe View Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question inadequate. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We found improvements were still needed with the incident and accident process to ensure there was a system to involve people, relatives and staff to learn from incidents collectively. The provider had a process in place for the management team to review incidents and accidents, however, staff and people living at the care home were not provided with the opportunity to reflect after incidents to ensure learning and improvements could effectively occur. The provider had made improvements to include staff and relatives in what was working and what improvements were needed since the last CQC visit. Staff and relative meetings had been completed to discuss the improvements the home needed to make to support people living at Kingsthorpe View. The provider told us they had completed lessons learnt since the last CQC visit and made changes to their processes and systems, but these did not involve staff or those living at the service. They had changed the providers audit visits from announced visits to unannounced visits to ensure they were seeing the service in a true reflection.

Care plans were reflective of people’s needs and included all the relevant information on how professionals were involved, and guidance was provided to staff to follow. However, people were not always provided with an opportunity to be involved with their care plans to ensure the information regarding them was accurate on how they wanted to be supported. This meant there was a risk information could be shared that was not always approved by people. The provider worked with healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. We found clinical staff were very knowledgeable of which health and social care professionals supported which people. The provider told us they had tried to access dental services for people since our last visit but had struggled to find a service to come into the home. They did have a process in place if people needed urgent dental treatment. However, one relative told us, “My mums’ teeth are still bad, and she has had a tooth fall out recently and not seen a dentist. I wasn’t made aware of this by staff. I visited and noticed she had a tooth missing. They [staff] did say mum can go back to access her own dentist.”

We found incidents records were not always accurately completed by staff to ensure the management team could make clear judgements and review if the records were required to be shared with the local safeguarding team. For example, a record showed that a person had pushed another person, however the manager told us it was not a push, and a person was falling towards a person. We found no records of an investigation to demonstrate the root cause to evidence what happened during the incident. Improvements had been made to people’s safety and we found there was a reduction in people being harmed from neglect. For example, falls had reduced because action had been taken to increase staffing levels and the management team had oversight of people’s personal care to ensure people received their support as assessed. We received mixed feedback from relatives if they felt their loved one was safe.

We were not fully assured people had clear strategies in place for when people showed signs of distress. For example, we observed a verbal altercation between two people. During lunch one person threw a drink over another person. Staff had responded but did not identify early warning signs and the risks of having people in the same room who were known to trigger distress to each other. A manager told us they would review the dining experience.

Relatives told us they had noticed an improvement and were more involved in their loved one’s care. Some relatives had been provided with an opportunity to read the care plan to ensure the information staff had to follow was accurate. We found a significant improvement with the management of pressure area care and wound management. People had accurate assessments in place and clear information and guidance for staff to follow.

The environment was not always kept safe. We found fire doors did not meet the required fire standards. For example, we found two corridor doors had the fire guard mechanism removed for refurbishment and not replaced, it was unknown how long these had been missing. This meant in the event of a fire, the doors would not automatically close to provide fire protection. This meant people were at risk of harm from fire due to poor implementation of fire prevention practices. The provider took immediate action during our visit and placed the mechanism back on. A legionella risk assessment was completed in June 2024 and identified risk actions to be completed. Some actions had been completed and two actions remained outstanding. This meant there was a risk of water-borne bacteria like legionella that could cause people harm. The management team told us the outstanding actions were booked in and told us after our visit the actions had been completed. We observed improvements since our visit to the fire exits, they were clear of blockages. People who liked to have their bedroom doors open had fire door guards fitted. This meant they did not have to wedge their bedroom doors open, and the door would close automatically in an event of a fire as required. Refurbishment had taken place to the garden area. The garden was more accessible and newer surface laid to ensure it was safe for people.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. We found staffing levels had increased since our last visit and this had a positive impact to people’s safety. A staff member told us, “Staffing levels now, is brilliant, we get so much more done and sometimes we get to have some one-to-one time with residents and have a chat. Extra staffing means it took the pressure off staff, and we can breathe and it's not as stressful anymore.” Another staff member told us, “They [management] have increased staffing, and it made it much better, means we can meet patient needs, support with personal care and cleaning after patients”. Staff told us they felt they had adequate training to do their role. Staff were provided with staff meeting opportunities. We received mixed feedback regarding have one to one supervision, some staff told us they had one and others told us they didn’t.

People and relatives told us improvements had been made and the home was clean. One relative told us, “They are having a lot of building work done at the moment, but there is no mess for the residents to fall over. It is kept clean, they clean up any mess, it doesn’t smell.” We observed housekeeping staff operating throughout the site visit. The home was clean, tidy and refurbishment work had been completed to ensure effective cleaning could be completed. We saw staff followed current practice when supporting people and that they used personal protective equipment (PPE) appropriately. PPE was available throughout the building and easily accessible for staff. There were policies in place to guide good infection, prevention and control practices and staff had completed infection, prevention and control training.

Medicines were stored securely. We found topical medication was not accessible to people who could come to harm. Health professionals had completed a review of the medicine management at the care home and told us they found significant improvements to systems and processes to ensure medicines were managed safely. On their last visit they had not identified any concerns. Staff had completed medicines training, and the management team had completed competency assessments to ensure staff were able to follow their training and administer medicines safely. People and relatives told us they didn’t have any concerns regarding medicines.