This inspection was completed on the 25, 26 September and 2 October 2018. The first day was unannounced, but the subsequent days were announced to enable us to meet with key staff and give feedback.Kingsacre is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The provider took over this service in June 2018, when it still provided nursing care, however since July 2018, they no longer provide nursing care on site. This is obtained from the community nurse team when needed.
Kingacre accommodates 34 people in one adapted building. The building is situated in a rural location standing in its own grounds. Communal areas are situated on the ground floor with bedrooms on the ground, lower ground and first floor, all accessed by a lift. The building is old and in need of some refurbishment.
Shortly after taking over this service the nurse team resigned, leaving the home very short staffed in terms of being able to cover nursing shifts. The provider made the decision to make the service a care home without nursing. They have worked with commissioning teams to review and move those people who required nursing care. They were in the process of changing the home’s registration so that it would no longer provide the regulated activity associated with being a nursing home.
This inspection was brought forward because of a number of safeguarding concerns which are being investigated by the local authority. This resulted in the service becoming part of a safeguarding process. This meant the local authority safeguarding team, commissioners, CQC inspectors, police and other professionals had met to discuss the safety and well-being of the people living at the service. The provider, their operations team and the registered manager had been part of these discussions. The findings of our inspection have also been shared with the local authority, so that they can form part of the safeguarding process. As part of this safeguarding process the provider had agreed not to admit any new people and the local authority have placed a hold on using this service for placements until improvements have been made. The death of one person and the circumstances surrounding that death were being looked at as part of a separate CQC process and does not form part of this inspection.
There was a registered manager in place who was also the registered manager of another service owned by the provider. 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 registered manager and provider had recognised that the current management arrangements were not working. The provider had employed another manager who would be applying to register with CQC to run Kingsacre. When this has happened the current registered manager would return to managing one service.
Some aspects of the service were not safe and placed people at potential risk. These included:
• Poor recruitment processes which meant staff were employed before all checks to ensure they were suitable had been completed.
• Fire safety information and risk assessments were not completed in a consistent way to ensure staff had reliable and correct information in the event of an emergency evacuation.
• Not all windows had restrictors fitted, and there were no regular checks to ensure restrictors were still in working order.
• Hoist slings were not used for a single person’s use- they were kept in communal areas and not named for individuals. This was an infection control risk.
• There were no risk assessments in place for bed rails, we identified one person had sustained an injury when their leg was caught in a bed rail without a protector being used.
• An oxygen cylinder had been placed next to a hot radiator in one person’s room- this was removed to a safer place when we fed this back, but the service was not even sure if the person still required oxygen.
• Some prescribed medicines were being used for people they were not prescribed for- i.e. thickener was found in one room which was prescribed for someone else. Systems for the use of topical creams needed improvement.
• Some areas of the home were not safe. The patio/balcony area had an uneven and wobbly floor. There was also an area of the home where carpet was old, worn and beginning to ruck, which was a trip hazard.
• Wheelchairs did not always have footplates. This placed people at potential risk of having their feet dragged when being transported, which could lead to injury.
• Pressure cushions had been used on top of cushioned chairs which altered the seating position of some people leaving their legs dandling and placing them at more risk of pressure damage.
• Not all pressure mattresses were set at the right setting for people’s weight.
Following the inspection, the provider wrote to us to say action had been taken to address and mitigate some of these risks. This included updating risk assessments, providing further training to staff and liaising with healthcare professionals to gain the right healthcare information for people. Detailed actions about how the service mitigated the risks can be found in the section related to safe.
Our observations of the days we inspected, as well as feedback from people’s and staff showed there were key times when there was not sufficient staff for the number and needs of people currently living at the service. Staff confirmed that most days they were still assisting people to get up right up to 12.30pm. The provider did not have a dependency tool to show how they had worked out staffing levels based on people’s individuals needs and dependency levels. During the morning people were left for long periods in the communal areas without supervision or support. Some people may have been at risk of choking and there was no staff having an oversight of people in the lounge and dining area throughout the morning.
Staff did not have the right skills and competencies to ensure people’s healthcare needs were being met. This was being addressed with some additional training and support from the community nurse team. The service had not always ensured new staff had an induction, or that there was ongoing support and supervision for staff to enable them to discuss their role and any training needs. Recruitment was not robust and placed people at potential risk.
The management arrangements were not clear to staff, staff did not feel valued or appreciated for the work they did. The provider said they would address this. They had already appointed another manager as they had recognised the current registered manager was struggling to manage two locations.
Quality audits had failed to pick up on aspects of health and safety, records and lack of meaningful engagement for people.
We found six breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to staffing, recruitment, the Mental Capacity Act (2005), safe care and treatment, person centred care and good governance.
You can see what action we told the provider to take at the back of the full version of the report.