Kensington Lodge

Updated 20 April 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection, we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was completed by an inspector and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Kensington Lodge is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Kensington Lodge is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection including the action plan submitted by the provider. We sought feedback from Healthwatch, Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

During the inspection we observed support people received throughout the day. We spoke with 4 people who used the service about their experience of the care provided and 2 relatives of people who use the service. We spoke with 4 health care professionals who regularly visited the service. We spoke with 7 members of staff including the registered manager, deputy manager, care staff and kitchen staff.

We reviewed a range of records. This included 4 people’s care records and multiple medication records. We looked at 2 staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service were reviewed.

Updated 20 April 2023

About the service

Kensington Lodge is a residential care home providing personal care to up to 18 people. The service provides support to people living with dementia, mental health conditions and age related frailties. At the time of our inspection there were 14 people using the service.

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

Quality assurance processes were not always effective to provide managerial oversight of systems and drive improvements. Areas of improvement highlighted from our last inspection were not fully resolved, records were not always confidentially stored. Audits of medicine management and the environment were not always accurate. It had not been identified some care records contained inconsistencies. The registered manager told us how they would make changes to make improvements on these issues

People’s health risks were not consistently assessed and managed safely. Some assessments were inaccurate, for example, where people had experienced weight loss, associated assessment tools were not always consistent with this. Despite the inaccuracies, care plans were detailed, reflected people’s needs and guided staff on how to safely support them. People told us they felt safe and were comfortable to speak with staff or the registered manager if they had any worries or concerns. One relative told us, “I’m thankful to all of them. She’s safe and she’s adjusted to being there. They’ve made a great effort with her.” Staff received safeguarding training and understood their duty on how to prevent and report potential concerns of abuse.

People received their medicines by staff who were trained and competent to administer them safely. People and their relatives were aware of any changes to their medicines. One relative told us, “It’s good and [registered manager] keeps us up to date.” People were protected from the risk of infection such as, the COVID-19 pandemic. Staff followed policies to keep people safe, wore personal protective equipment (PPE) and practised good hand hygiene. The registered manager told us they would review their policy of the continued use of face masks to reflect current government guidance.

People were supported by enough staff who knew them well. Staff were recruited safely and received training relevant to their role. People were complimentary of the care staff. One person told us, “I talk to them a lot. I know them.” A relative commented, “They’ve got to know [person] and me. They make an effort to chat. I have a good relationship with them. If I’m not able to go in, they ring and tell me how my relative has been. They’re lovely.”

People and their relatives were involved in planning their care and were given opportunities to give feedback on the service. People, their relatives and staff told us they felt comfortable to make suggestions, they were confident the management team would deal with any ideas or problems. Relatives told us staff and management kept them up to date with changes to their loved ones. One relative said, “The way they communicate with me, with the families. They make you feel very comfortable so you can talk freely with them.”

Staff and the management team worked closely with health and social care professionals to improve people’s care, safety and well-being. One visiting health care professional told us, “When I have asked them to review something they have always followed my instructions. Staff seem caring, I haven't had any concerns.”

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

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 19 November 2021). We found a breach of regulation 17 (good governance). The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found the provider remained in breach of regulation 17.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection. We carried out an unannounced comprehensive inspection of this service on 15 October 2021. A breach of legal requirements was found. The provider completed an action plan after the last inspection to show what they would do and by when to improve good governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has remained requires improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Kensington Lodge on our website at www.cqc.org.uk.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Enforcement

We have identified a breach in relation to good governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from 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 continue to monitor information we receive about the service, which will help inform when we next inspect.