Archived: Kesson House Care Home

Kesson House Care Home is a residential care home providing personal care to 27 people living with a range of complex health needs including dementia or aged 65 and over at the time of the inspection. Kesson House Care Home accommodates up to 38 people in one adapted building.

People’s experience of using this service and what we found

People received inadequate care. This had a major impact on their health, safety and well being. The provider did not have clear oversight of the service and their quality assurance process had not been robustly followed. Action taken to keep people safe had not been effective and people had suffered harm. We found significant shortfalls in people’s care and support: these shortfalls had not been identified by the provider, their management team or staff.

Leadership of the service was inadequate. The provider had failed to ensure the service was appropriately managed or led. The manager was new in post and was the third manager in a year. The service had not developed a positive culture centred around people and their safety.

Important infection control guidance from the government, in relation to managing Covid-19, had not been followed and this put people at risk of contracting the disease. People were in the highest risk groups of dying from Covid-19.

Safeguarding risks had not been identified and managed to keep people as safe as possible. One person had been assaulted. Staff had not informed the local safeguarding team of incidents so they could investigate and offer support. Some people were living with dementia and had behaviours which challenged at times. Guidance had not been given to staff about how to avoid or defuse situations to ensure people were safe and their needs were met.

Risks to people had not been kept under constant review and changes in people’s needs had not been identified. For example, action had not been taken when people had lost weight increasing people’s risk of developing pressure ulcers and falling. We had not always been informed of serious injuries to people so we could check they had received care to keep them safe and well.

Staff had not been constantly deployed to the levels the provider had assessed were required. This had a major impact on people’s safety and their health. People did not receive the care they had been assessed as needing. In addition, people frequently had to wait for their care and support, and this caused them distress. Some staff did not have the basic skills they needed to keep people safe, such as moving and handling or medicines training. The provider sent us further evidence following the inspection about action they had taken in respect of staffing, but that this did not fully mitigate the risks.

Medicines were not well managed, and people did not always receive their medicines as prescribed. Medicines had been out of stock, others had been not been given and one person had been given to much.

Following the inspection the provider met with the commission and sent us an action plan to address the urgent issues, however this did not fully mitigate the risks.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was Good (published 26 June 2019).

Why we inspected

We undertook this targeted inspection to check on specific concerns we had about management of medicines and infection control risks, people’s care and treatment, people losing weight and poor governance and leadership. The overall rating for the service has not changed following this targeted inspection and remains Good.

CQC have introduced targeted inspections to follow up on Warning Notices or to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to risk management, protecting people from the risks of harm and abuse, medicines management, staff deployment, infection control, monitoring and improving the quality of the service and governance this inspection.

Following our inspection we used our urgent enforcement powers to vary the providers conditions of registration. This was to restrict admissions to the service. After our inspection the provider informed us they were closing the service and people were moved from the home.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

What life is like for people using the service:

By observing, listening and talking to people we found people benefited from a safe and caring service. We often heard staff saying kind things to people and observed that staff were attentive to people’s needs. People told us they experienced safe care.

The care was offered based on policies about Equality, Diversity and Human Rights. Staff worked in partnership with people, health professionals and families.

People told us that staff met their needs with care and were friendly towards them.

Training, policy guidance and safe systems of work continued to minimise the risk of people being exposed to harm.

People’s needs were fully assessed and people’s right to retain independence in their day to day lives was respected. Staff understood how to safeguard people at risk and how to report any concerns they may have.

The individual risks people may face were assessed and the actions to minimise risks were recorded. Care plans had been developed to assist staff to meet people’s needs. The care plans were consistently reviewed and updated.

Incidents and accidents were recorded and checked or investigated by the manager to see what steps could be taken to prevent these happening again.

The premises were adapted to people’s needs to make them dementia friendly, accessible to people with mobility problems and equipment was routinely serviced and maintained.

People, their relatives and health care professionals had the opportunity to share their views about the service.

Complaints made by people or their relatives were taken seriously and thoroughly investigated.

Safe recruitment practices had been followed before staff started working at the service.

Staff had the training, skills, supervision and experience to meet people’s needs.

There were policies and procedures in place for the safe administration of medicines. Staff had been trained to administer medicines safely.

A range of food choices were offered including those that met their cultural needs and people were encouraged by staff to eat healthily.

People had access to GPs and their health and wellbeing was supported by prompt referrals and access to medical care if they became unwell.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

Staff followed good hygiene practice to minimise the risks from the spread of infection.

The service could continue to run in the event of emergencies arising so that people’s care would continue.

Rating at last comprehensive inspection: Good (report published 09 November 2016).

Why we inspected: This was a comprehensive inspection scheduled based on the previous rating. The inspection was brought forward due to concerns raised by a whistle blower. We found the evidence continued to support a Good rating.

Follow up: We will continue to monitor the service through the information we receive.

There was a registered manager in post who had applied for registration with the CQC. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The provider had ensured that there were appropriate systems in place to identify and minimise risk for people living at the service. Risks to people's safety had been assessed and actions taken to protect people from the risk of harm

Medicines were managed safely and people had access to their medicines when they needed them.

There was a sufficient number of staff deployed to provide care to people throughout the day and night. When staff were recruited, they were subject to checks to ensure they were safe to work in the care sector.

People were protected from abuse by trained staff who could identify the forms of abuse and who knew who they could report to. The provider had effective safeguarding systems in place.

Kesson House provides care for up to 38 people who may be living with dementia and there were 30 people using the service on the day of the inspection. The home is situated in Gravesend, Kent.

There was a registered manager in place at the time of the inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The administering and recording of medicines were not always carried out safely and according to the homes policies and procedures. There were issues identified with recording temperatures in the clinical room, discrepancies with signing and the use of handwritten medicine administration records (MARS) as well as following guidance in relation to ‘when required’ medicines, known as PRN.

Incidents and accidents were appropriately recorded. However they were not always monitored appropriately in order to identify and minimise risks.

There were risk assessments on each of the care records we looked at. These assessments were specific to the individual, for example, where a person had diabetes, the risk was assessed in relation to diet and nutrition and the risks relating to high and low blood.

There were regular checks and audits taking place to monitor the quality of the service.

There were systems in place to safeguard people and staff had a good understanding of the different types of abuse and the signs they would look out for. There were appropriate arrangements in place for responding to emergencies and evacuating the building.

Recruitment practices ensured staff were appropriately checked prior to employment to ensure they were suitable to work with the people using the service. There were sufficient staff available and deployed to meet people’s needs.

Staff received training and support to help them carry out their work role and demonstrated good knowledge on the subjects they were asked about, including promoting independence, choice, dignity, engagement and person centred care.

Staff had received training in the Mental Capacity Act 2005 (MCA) and the Depravation of Liberty Safeguards (DoLS).They were able to describe people’s rights and the process to be followed if they were identified as needing to be assessed under DoLS.

People were supported to eat, drink and maintain a balanced diet. There were up to date menus displayed in the dining room. People told us they enjoyed the food and that they were involved in choosing the menus.

People were supported to keep well and had access to the health care services they needed.

Staff received training on equality and diversity and the service had policies and procedures in place for staff to refer to. Aspects of people’s unique needs relating to this were included in peoples care plans, including race, sexual orientation and beliefs.

A copy of the complaints leaflet was on display on the notice board at the service. Staff knew how to support people appropriately to make a complaint.

There were mechanisms in place to ensure people and their relatives had regular feedback. This included regular residents meetings, resident surveys and regular discussions with management.

During the inspection the expert by experience spoke with all five of the people who lived at the service and two of their relatives. The service had reopened earlier this year and was not at full capacity at the time of this inspection. We spoke with two staff, one of which was a senior staff member, the manager of the service and the regional operations manager. We looked at records relating to people's care, medicines, staff training and the monitoring of the quality of the service. We considered all of the evidence we had gathered under the outcomes we inspected. We used this information to answer the five questions we always ask; is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found

Is the service caring?

The atmosphere at the service was calm and friendly. We saw that staff were kind towards people. People told us they had every confidence in the staff and that the staff were caring at all times. Two relatives confirmed this. One person told us, 'They will always ask me if things are ok, if I'm happy, or if they can get me anything else.'

Is the service responsive?

One person told us 'I'm glad that staff here notice if I'm not right. They'll call the doctor if they are worried, and [the doctor will] always come. I feel I'm well looked after here.' A relative told us, 'I feel confident that my [relative] is in safe hands here and can go home without worrying that anyone is ever unkind to [their relative] here'.

One person's records showed when they had declined to have their weight checked. We saw that the manager had responded to this by arranging for staff to monitor their food intake to ensure their health. Records confirmed that staff were doing this regularly.

We saw that the service accessed the support from health professionals when required.

Is the service safe?

At our inspection on 21 August 2014 we identified concerns in relation to staff training, in that staff had not received the training required to meet the needs of the people who lived at the service. At this inspection we found that improvements had been made in relation to staff training. Staff were in the process of completing their induction workbooks and we saw that these workbooks covered topics relevant to the needs of people who lived at the service such as dementia.

We saw a training record that included nine healthcare assistants including seniors and one activities' coordinator. This record showed that the majority of these staff had completed training in dementia, adult protection, the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards (DoLS). All of these staff had completed training in safely managing people whose behaviours may challenge others.

At our inspection on 21 August 2014 we identified concerns in relation to the management of people's medicines. We found that appropriate steps had not been taken to ensure that people received their medicines as prescribed. A record had not been made to show what medicines one person had brought with them when they had moved into the service. There were no processes in place for recording when medicines were returned to the pharmacy. Records did not accurately show the levels of medicines in stock at the service.

We found that staff administering medicines had not been assessed to check their competence in relation to administration of medicines. This was not in line with the service's own policy on medicines.

At this inspection we found that improvements had been made to the way in which medicines were managed at the service. Records related to medicines were appropriately maintained and filled out with complete information. There was a record of the medicines people had brought with them and what was in stock. This meant it was possible to account for all of the medicines at the service.

We saw records that showed that staff had undertaken further training on medicines and their competency had been checked using a written assessment as well as observation of the staff as they administered medicines.

Is the service effective?

At our inspection on 21 August 2014 we identified concerns in relation to the planning of care to reflect one person's individual needs. The person's care plan did not describe behaviours that challenge associated with their dementia. The system in place to record this person's fluid intake was also not being used effectively and no action had been taken in response to their weight loss to ensure their welfare and safety.

At this inspection we found that improvements had been made to the planning of people's care. We saw that there were detailed care plans in place that provided written guidance for staff to follow in response to behaviours associated with people's dementia. We spoke with staff who knew how to deliver the support people needed in relation to their dementia.

There were now arrangements in place to effectively monitor people's fluid intake where it had been assessed as necessary to do so to promote their health. We saw that where people required their weight to be monitored this had also been done regularly.

Is the service well led?

At our inspection on 21 August 2014 we identified concerns in relation to the monitoring of the quality of the service. We found that although there were some systems in place to monitor and assess the quality of the service these were not being consistently applied. Audit tools were in place however, they had not been used consistently to identify the areas of concern we found during our inspection.

We saw one example of a record not being promptly located and two examples of records not always being accurately maintained in respect of people who lived at the service.

At this inspection we found that improvements had been made in relation to the management of the service. A new permanent manager had been in post for approximately three months at the time of inspection. One person told us 'We had a new manager recently, maybe two months or so ago, and [the manager] has made so many changes, all for the better. [The manager] has made the world of difference here.' The manager told us they had applied to become the registered manager of the service.

We saw records that showed regular audits of medicines were being undertaken. These had not identified any concerns that needed to be addressed by the service. We saw that daily audits were being carried out by the manager and changes had been made in response to matters identified. We saw that this record also monitored whether the charts recording people's fluid intake had been correctly completed.

Regular infection control audits and health and safety audits were carried out. This meant that checks were in place to ensure the premises were suitable and safe for the people who lived at the service, staff and visitors to the service.

We saw records that showed the regional operations manager was consistently carrying out audits and that actions identified as a result of these audits were implemented.

We found that improvements had been made in relation to records at the service. For example, records could be located promptly when required.

Below is a summary of what we found

Is the service caring?

The atmosphere at the service was calm and friendly. We saw that the staff at the service were caring towards people who lived there. During the inspection we saw two occasions when one person became upset. We saw that two different staff responded to each occasion in a kind way and lowered themselves down to this person's seated level to speak with them. Staff used touch in an appropriate way to provide warmth and reassurance to this person who was distressed. One person we spoke with told us that there was a 'Nice bunch of staff'. They had seen the doctor and a nurse in relation to their health. Another person told us that 'It is heaven' in relation to living at the service. They added that the staff took care of them. A relative we spoke with told us that the staff were always caring towards their family member.

Is the service responsive?

There was a process in place to ensure people's needs could be met by the service before the person came to live there. We saw two examples of a written assessment for each person who lived at the service.

We saw that one person had a health concern the morning of the inspection. Later we saw a record that showed this matter had been reported to a doctor. This meant that staff responded to this person's health concern promptly.

We saw that the service accessed the support from health professionals in relation to people's mobility. For example, records showed that one person had been referred to a falls clinic, even though they had not fallen. This meant that advice was being sought from relevant health professionals in response to a concern about this person's risk of falls.

Is the service safe?

The environment had been refurbished and was clean and safe for the people who lived there to move around. There was a robust recruitment process that followed legal requirements. However, the induction training for staff had not been implemented fully and staff had not always had training in key areas related to the needs of the people living at the service. Two staff had not completed a competency check in relation to administering medicines. Arrangements were not always in place to ensure the safe management of medicines.

A daily fluid balance chart instructed staff to 'Inform registered nurse immediately if the output is greater than the intake' for one person. We saw that on seven occasions between 21 July 2014 and 20 August 2014 the output was greater than the input. There was no written information in these notes to show that staff had reported the output being greater than the input to the relevant health professional to ensure that this person's health was maintained.

Records showed that one person had lost 4.5 kilogrammes in weight between 30 June 2014 and 12 August 2014. There was no written information to show that this weight loss had been reported to a relevant health professional to ensure this person's health needs were met.

Is the service effective?

There were enough staff on duty to meet people's needs. People's privacy, dignity and independence was promoted. People were involved in day to day decisions about their care. People's nutrition needs were met. People were given the opportunity to participate in activities at the service.

We found that proper steps were not in place to ensure that the planning of care reflected one person's individual needs, as the care plan did not describe the behavioural difficulties related to their dementia. Records showed 10 incidents involving this person between the end of July 2014 and late August 2014. A senior staff member told us that there was no written plan in place for staff to follow about how to respond to this person's distress.

There was a system in place for staff to record the fluid intake and output for this person. Between 21 July 2014 and 20 August 2014 records showed 21 occasions when staff had not entered the total amount of fluid input and/output. On three occasions the total amount of fluid input was under the minimum amount required in a twenty four hours period as it was below 1200mls. This meant that the delivery of this aspect of this person's care did not ensure their welfare and safety.

Is the service well led?

The service had been open for approximately two months at the time of our inspection. There had been two managers in post during this time. Management cover arrangements had been in place during this time.

We found that effective systems to monitor the quality of the service were not always in place. Where monitoring systems were in place they were not always used effectively. There was a system in place for the manager to audit aspects of the service on a daily basis. However, this audit was not carried out every day. Records showed that this system was not effective at identifying areas that required improvement, including the completion of fluid monitoring charts. This showed that the audit was ineffective in identifying issues around fluid monitoring. Therefore, this system did not identify or manage the risks relating to this person's health.

We looked at infection control audits and health and safety audits that had been implemented to ensure appropriate standards of hygiene and health and safety were maintained at the service. We saw that both these audits had been partially completed on 20 May 2014. Neither had been completed subsequently when people had moved into the service. This meant that effective systems were not in place to assess and monitor the quality of the service in relation to standards of hygiene and health and safety.

We saw that the service had a weekly audit concerning medication. One audit had been completed that showed a medication had not been carried over correctly. This meant that issues such as those identified on the day of our inspection had not been identified and addressed.

The regional operations manager completed an audit of the service in July 2014. They identified issues including the fact that not all staff had been assessed to ensure they were competent to administer medication. An action plan had not been developed to address any shortcomings. This meant that the auditing tool was not effective as a way to monitor and assess the quality of the service. During the inspection we identified concerns relating to staff competencies to administer medication. This showed that processes in relation to quality assurance were not fit for purpose.

We saw one example of a record not being promptly located and two examples of records not always being accurately maintained in respect of people who lived at the service.

We found that staff were not suitably trained to care for people with dementia or for those with complex care needs. We found that staff lacked the skills, attributes and in some cases, the compassion and empathy to care for the service users at St Peters Nursing Home. Staff told us that they did not know how to appropriately interact with people with dementia. We observed staff talking over service users as well as using sarcastic and patronising language.

Service users had not routinely been protected against the risk of financial abuse.

We noted that there had been a very high incident rate for the period between July 2012 and January 2013. A total of 176 incidents had been reported, of which 88 incidents had resulted in some form of injury such as a skin tear, or bruising. There had been no analysis of these incidents. Where risk assessments had been completed, we found that these had had little impact on the frequency with which people were sustaining injuries as a result of slips, trips and falls. This is unacceptable and has exposed people to harm.

We saw that the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.

We found that people were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

We saw that internally the building was in poor decorative condition and in need of maintenance however we did see many maintenance people at the home during our inspection engaged in repairs. We found that service was not keeping records to show it was addressing required maintenance in a timely manner, or in a way that would ensure the prioritisation of work that most affects the comfort, health and safety of people they provide they care for.

Relatives we spoke to said that the same members of staff were generally on duty and this was beneficial for people.

During lunch we saw that one member of care staff was left responsible to care for eight people which included feeding four of them at the same time and at times people were left unsupervised..

We saw that there was not records of what staff training had been delivered prior to three weeks ago.