Kingswood Manor

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• 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

We found breaches of the legal regulations in relation to safe care and treatment. Serious concerns were identified with medicines management and fire safety. Some concerns were identified in respect of care planning and premises management overall. Improvements to care plans had been made however further improvements were required to ensure people’s physical and medical conditions were properly assessed, described and care plans consistent. People’s needs and risks in relation to end of life care and dementia also required further explanation to ensure staff knew how to support these needs appropriately. The safety of medicines had declined further since our last inspection. A significant number of people had not received the medicines they needed to keep them safe and well. Some people had not been given their medicines in a safe way in accordance with the prescriber’s instructions and records in relation to the application of prescribed creams and thickening agents in people’s drinks were not accurate. This increased the risk of people’s physical and medical conditions not being properly treated. At the last inspection, serious concerns with fire safety were identified and a referral made to Merseyside Fire and Rescue. At this inspection, no robust improvements. A second referral was made to Merseyside Fire and Rescue to mitigate risks of avoidable harm in the event of a fire. Other premises issues identified at the last inspection had also not been robustly acted upon. Safeguarding events had been appropriately responded to, with action taken to mitigate potential risks. Some safeguarding incidents had not always been reported to CQC in accordance with legal requirements. Improvements to staff recruitment and training had been made. Staff received appropriate supervision and staffing level this inspection were safe. People told us they felt safe, able to raise any concerns they had about their care felt staff knew them well.

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.

People were confident any concerns they had about their care would be listened to and acted upon quickly.

The manager monitored accidents and incidents across the service. Staff knew what action to taken when an accident or incident occurred.

There was a clear system in place to record accident and incidents that occurred in the home. Records showed appropriate action was taken when an accident and incident occurred. Complaints about the service were listened to and responded to appropriately.

Relatives told us that other professionals were referred to and involved in the person’s care to maintain their safety. One relative told us “They ordered liquid meds for my husband and the Pharmacist included me in discussions which was good”. Another said, “My husband is on a soft diet, and they are doing SALT assessments to see if he can have more solid food".

The manager told us people’s needs were assessed prior to admission then care plans developed. They told us that people’s needs were reviewed monthly. Records confirmed this. Staff told us that information about people’s risks were documented in care plans and a daily handover meeting gave them updates on people’s needs and risks.

The local authority recently audited the provider’s admission process and found it satisfactory.

Systems were in place to assess people’s needs and risks and plan their care. Some care plans however were not fully developed to ensure that people experienced continuity of care at all stages of their support including at the end of their life and with dementia. There was also a serious lack of safety around the management of medicines. This interrupted the continuity and effectiveness of people’s treatment for medical or health conditions.

People told us they felt safe living in the home and able to share any concerns. Relatives confirmed this. Their comments included, “I have lived here for about a year, yes I feel very safe here”, “I suppose I feel safe. It’s not like my own home but it’s ok…I’ve been here about 9 months”, “oh yes I feel very safe here“, and “My mum is safe here. We needed to find somewhere good enough and this is”.

Staff had completed safeguarding training and knew how to report potential abuse. The manager and regional manager were able to describe what action they had taken to protect people from the risk of abuse. Records confirmed this. We found however some safeguarding incidents had not been recognised as safeguarding events that required notification to CQC. For example, falls where safety equipment had not been in applied. These events had been referred to the Local Authority but not CQC.

We observed staff to be kind and caring. People and their relatives confirmed this.

There were safeguarding policies and procedures in place to advise staff of the action to take in the event of possible abuse. Clear records were maintained of recognised safeguarding events, which included details of any investigations and action taken. There was a record maintained of people living in the home subject to deprivation of liberty safeguards (DoLS) for staff to be aware of.

Staff supported people to manage risks associated with everyday tasks such as washing and dressing, eating and drinking and mobilising around the home. However, people’s wellbeing was placed at risk as a result of shortfalls in care planning and medicines management.

The manager told us daily handover meetings took place. A staff member confirmed this. They told us, “There is a daily meeting with seniors and heads of department, where learning from incidents are shared. Handovers (between shifts) also place in morning where staff are informed of any changes, risks etc”. A staff member told us, “Risk assessments are on the PCS system and outline any risks. Another said, “Risks are documented in care plans/risk assessments” It was clear that staff knew where to locate information in respect of people’s needs and risks. We found however although information about people’s needs and risks had improved since the last inspection, further information was required on some people’s medical needs and care and some people’s care plans were not sufficiently detailed for staff to ensure all risks were mitigated.

We observed staff providing appropriate support to people with mobility needs and those who required support to eat and drink.

Care and risk management plans had improved since our last inspection. It was clear that time had been spent developing care plans so that staff had better information on people’s needs and risks. We found however that there were still discrepancies and lack of clarity in some areas. For instance, some people’s medical conditions were not fully described. People’s wishes for end of life care were not always documented. Records in relation to wounds and wound management were not properly maintained and information about some aspects of people’s care was contradictory for example, mobility, communication, medicine allergies. This meant there was an increased risk that people’s care and treatment would not fully mitigate risks to their health and wellbeing.

People raised no concerns about the environment in which they lived. We found however that improvements were required to keep people safe and comfortable.

At the last inspection, concerns were identified with some of the home’s fire doors which were not compliant with fire safety requirements. At this inspection, insufficient progress has been made to ensure fire doors were effective in the event of a fire. The manager told us that an ongoing refurbishment plan was in place and provided a copy of the fire door refurbishment plan. This refurbishment plan still showed the majority of the home’s fire doors needed repair or adjustment to be effective.

Some of the home’s fire doors did not fully fit their frames. This increased the risk of smoke and fire being able to spread across the home.

There was a process in place to monitor fire safety. However, there was a lack of urgency and solid commitment to ensuring timely and robust action was taken when fire safety provisions were not adequate. At the last inspection in October 2023 serious concerns were identified with the effectiveness of the home’s fire doors. Merseyside Fire and Rescue Service visited the service in November 2023 and identified concerns with the home’s fire doors and other aspects of fire safety. Despite this, at this inspection, serious concerns with regards to fire doors were identified again. It was clear the provider had failed to take appropriate action to ensure fire safety arrangements were robust to protect people from avoidable harm. Other aspects of the home’s environment required improvement. Some of the home’s window frames were rotted, with some window held open with blocks of wood and other items. Two bedroom windows had cracked panes of glass that not been addressed since the last inspection. Carpets in communal areas were stained and unsightly and some people’s bedrooms smelt unpleasant. The home was not a dementia friendly environment. There was a lack of adequate signage in some areas of the home to help people navigate around the home easily. For example, some bedrooms doors had signage to help people identify their own bedroom, whereas others did not. The process in place to ensure the environment in which people lived was safe and suitable was not robust.

Two people we spoke with said at times the home could benefit from more staff especially at night time. Their comments included, “They sometimes could do with more especially at night”, “and “I need help with the toilet and most of the time they come but if they’re busy a few minutes can seem a long time”. Most of the people we spoke with however raised no concerns about staffing levels in the home.

The manager told us that staffing levels were sufficient and corresponded with the levels determined as safe by the provider. Staff felt overall staffing levels were sufficient, but one staff member told us some days were busier than others but they did their best to meet everyone’s needs.

At the time of the inspection, there were enough staff to support people’s needs. Rotas were planned in advance for staff to be aware of.

At the last inspection, staffing levels were not safely determined and there were significant gaps in the care people received. At this inspection, we found that staffing levels were sufficient to meet people’s needs. Records confirmed this. We recommend however that the provider considers the use of a more specific tool to determine safe staffing levels in respect of nursing care should occupancy levels in the home increase. At the last inspection, staff had not received adequate training, supervision and support to do their job role. They had also not received an annual appraisal to evaluate their job performance. At this inspection, improvements had been made. Staff had completed appropriate training, supervision and appraisal.

People told us the home was clean.

Staff told us they had sufficient supplies of personal and protective equipment (PPE) and knew what action to take to prevent the spread of infection.

The home was overall clean. Parts of the home required re-decoration. PPE was observed in communal corridors for staff and visitors to access if needed.

At the last inspection, standards of infection control were poor. At this inspection, sufficient improvements had been made. The home was clean with a daily cleaning schedule in place. The NHS infection control team had audited standards in the home in June 2024. The home scored 97%, which was a significant improvement since the last inspection.

At the last inspection, serious concerns with the management of medicines were found. At this inspection, we found that the management of, and people’s experience of medicines had declined further. People did not always have their medicines as prescribed and when they needed them, because there was no stock available in the home. Fifteen people had missed doses of their medicines in a 30-day period. One person did not have their laxative for a week and other people did not have their creams applied for up to 10 days because there was no stock in the home to administer. This placed people at risk of harm. People prescribed time sensitive medicines did not always receive them at the correct times or with a safe time interval between doses. For example, medicines that should be given before food or on an empty stomach were given with medicines that should be given with or just after food. This meant there was a risk these medicines would not work properly. In addition, one person was given doses of their pain relief too close together placing them at risk of an overdose. When people were prescribed medicines and creams to be administered ‘when required’ or with a choice of dose the guidance to support their safe administration was not person centred. This meant staff did not always have enough information to tell them when someone may need the medicine, how much to give or which medicine to give if more than one medicine was prescribed to treat same condition.

The manager and regional manager had not identified or addressed any ongoing concerns with medicines appropriately.

At the last inspection, the processes in place to ensure medicines were given safely were poor. At this inspection, we found no robust improvements to the management of medicines had been made. Record keeping in respect of medicines was also not accurate and the processes in place to ensure the safety of medicines were not effective. For example, nurses signed for creams and eye drops that they had not applied. This meant that although the records showed people had received their treatment as prescribed, they had not. The location of transdermal pain relief patches was not recorded, so it was not possible to tell if they had been applied safely. Records about stock levels were also inaccurate which meant it was not possible to account for all the medicines in the home or provide evidence that people had been given their medicines safely. The processes in placed failed to ensure people received the medicines to maintain their physical wellbeing and comfort. Clinical and managerial oversight of medicines was poor.