We carried out a comprehensive inspection of Kingswood House on 17 and 18 April 2018. The inspection was unannounced.

Kingswood House is a care home. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

Kingswood House is registered to provide accommodation for people requiring nursing or personal care and treatment of disease, disorder or injury for up to 22 people and younger adults with mental health support needs. At the time of the inspection there were 22 people living at Kingswood House.

There was a manager in post who was currently in the process of applying to be the registered manager for the service. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 manager was fulfilling the role and responsibilities of the registered manager until they were formally registered.

We last inspected the service in August 2017. At that inspection, we identified a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We issued a warning notice to the provider asking them to take immediate action in respect to the following issues; Risks to people’s health and safety were not adequately assessed and action was not being taken to do all that is reasonably practicable to mitigate risks including; risks from insufficient fire safety and infection control measures at the premises, risks of pressure damage and injury from incorrectly fitted lap belts to people. Systems or processes to assess, monitor and improve the quality and safety of the services provided were not operating effectively.

We also asked the provider to make improvements to address the following issues; People’s care and treatment was not always being provided with their consent and the provider was not always acting in accordance with the Mental Capacity Act (MCA) 2005. Premises and equipment used by the service was not always clean, suitable for their purpose and properly maintained.

At this inspection we checked to see if the provider had taken actions to address these issues.

The provider had implemented control measures to reduce the risk of infection. However, issues with the staffing arrangements and people’s behaviour were impacting on the effectiveness of the measures at the time of this inspection and this required improvement. The manager was aware of the issues and was acting to address this.

Systems and processes were operating effectively in assessing and monitoring quality and safety of the service. Where areas of practice required improvement and effective action had not yet been completed, evaluation and learning based on current performance was taking place to drive on-going improvement and avoid future delays.

There was a planned schedule of works in progress and other actions had been implemented to ensure premises and equipment were suitable for purpose and properly maintained.

Risks to people’s health and safety from insufficient fire safety measures, risks of pressure damage and injury from incorrectly fitted lap belts to people had been effectively addressed. People’s support was appropriate and being provided with their consent, in accordance with the principles of the MCA.

Ordering, disposal and storage of medicines was being carried out safely. However, medicine recording systems were not always managed properly and guidance for people’s ‘as and when’ (PRN) medicines lacked detail about when these should be administered.

People told us they felt safe. The service had enough staff and there were

This inspection took place on 21 and 22 August 2017. The first day was unannounced. Kingswood House is registered to provide nursing, care and accommodation to 22 people. There were 19 people living in the home when we visited. People living there were all adults who were living with past or present mental health nursing and care needs. Some people had additional needs in relation to substance dependency. Some people had needs relating to medical conditions such as living with diabetes, stroke or epilepsy. For some people Kingswood House was their permanent home, for others they were living at Kingswood House for a period of time before they moved on to other accommodation, or back to their own homes.

Kingwood House provides accommodation over three floors. There were communal sitting rooms and a dining room on the ground floor, and a patio and garden to the rear. The house was situated close to the middle of St Leonards.

There was a registered manager in post. 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 is Inwood Limited. Kingswood House is the only home Inwood Limited is registered for.

The home has been inspected twice since 2015. At the inspection of 24 and 25 August 2015, the home was rated as inadequate and six breaches in the HSCA 2014 regulations were identified. The home inspected again on 21 and 26 April 2016. At that inspection improvements were identified and it was rated as requires improvement, however a continued breach in Regulation 12 of the HSCA Regulations 2014 in relation to safe care and treatment continued to be identified.

At this inspection, we found the provider and registered manager had not been successful in making all relevant improvements and several areas identified at the inspection of 24 and 25 August 2015 were again identified.

As at the last and previous inspections issues relating to safe care and treatment were identified. This was particularly in relation to the high risk to fire safety. Areas relating to the mitigating of risk to people and cleanliness were also identified, as they had been at the inspection of 24 and 25 August 2015.

At the last inspection improvements were required to ensure the service was well-led. This related particularly to the provider’s systems of quality assurance which had not been effective in identifying matters and ensuring appropriate action was taken. As at the last and previous inspections, the provider continued not to identify all relevant actions, some matters were not documented and some areas did not have action plans to outline how they were to be addressed. This related to a range of areas, including audits of care planning and maintenance of the home environment, as well as safety.

People were not supported by person-centred care plans relating to their daily lives to ensure their individual needs for activity and engagement were assessed, planned with them, and reviewed. This had also been identified at the inspection of 24 and 25 August 2015.

The home environment needed attention to a wide range of areas to ensure it provided a clean, therapeutic and homely place for people to live. This had also been identified at the inspection of 24 and 25 August 2015.

The provider was not ensuring it complied with all relevant areas in accordance with the Mental Capacity Act (2005), to ensure people were supported appropriately in consenting to care and treatment, or if they were not able to do so, such care and treatment was provided in their best interests.

Staff were trained and supported in their roles, however we recommend that the service follow current guidelines in relation to the induction of new staff. Safe staffing levels were maintain

The inspection was carried out on 21 and 26 April 2016. The service provides personal, nursing care and accommodation for a maximum of 22 people.

The staff provided nursing and personal care for people with enduring mental health conditions, some of whom had a history of substance or alcohol misuse and a previous criminal background. Some people also had complex physical health conditions and behaviours which may challenge.

There was a registered manager in post. 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.

At our last inspection on 24 and 25 August 2015 the service was placed in special measures. The purpose of special measures is to ensure that providers found to be providing inadequate care significantly improve. This also provides a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

At this inspection we found the registered manager, management and nursing team had made improvements to the service. We have judged the service is no longer in special measures. Whilst improvements have been made, there are some areas identified for improvement.

Fire safety measures in place were not sufficiently robust to ensure people would be safely evacuated in the event of a fire.

The quality assurance system in place effectively identified all service shortfalls. However fire safety shortfalls had not been addressed to reduce potential risks to people in the event of a fire.

Staff received regular supervision to discuss their needs. However, supervision records did not consistently and clearly show what action had been taken to address staff development needs to ensure people received effective care. We have made a recommendation about supervision records.

There was an effective maintenance system in place and the provider had made a number of improvements to the building since the last inspection.

Staff had attended training in how to protect people from abuse and harm. Staff were confident in describing how they would recognise potential signs of abuse and what processes they needed to follow to keep people safe. There were safe recruitment procedures in place which included the checking of references.

There was sufficient staff to meet people’s needs. There was a robust management and nursing team in place to support the effective operational and clinical management of the service.

Accidents and incidents were recorded, monitored and analysed to identify how the risks of re-occurrence could be reduced to keep people safe.

Medicines were stored, administered, recorded and disposed of safely and correctly. Staff were trained in the safe administration of medicines and kept relevant records that were accurate.

The provider had a system for monitoring the cleanliness and maintaining effective infection control standards at the home. We found the home was clean.

Staff had attended training required for their role. Annual appraisals had taken place, to assess and support people’s training and development needs.

The Care Quality Commission (CQC) is required by law to monitor the operation of Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Where people required a DoLS the registered manager and senior staff team had completed DoLS applications appropriately. They understood when an application should be made and how to submit one.

Staff were able to describe the basic principles of the Mental Capacity Act (2005) (MCA) to ensure they supported people legally in line with their consent. Staff had completed training to understand the requirements of this legislation.

The service

The inspection was carried out on 24 and 25 August 2015 by two inspectors, a specialist clinical adviser and an expert by experience. It was an unannounced inspection. The service provides personal, nursing care and accommodation for a maximum of 22 people.

The staff provided nursing and personal care for people with enduring mental health conditions, some of whom had a history of substance or alcohol misuse and a forensic background. Some people also had complex physical health conditions and behaviours which may challenge. Many people stayed at the service on a long term basis and may previously have experienced homelessness. The provider told us they aimed to support people to move to more independent services if their health needs allowed this, to enable them to live without full time support and nursing care.

There was an acting manager in post who was acting up from a previous deputy manager role. The previous registered manager had recently resigned from their role. The service was in the process of recruiting a new full time manager who was due to take up the post, dependent on satisfactory recruitment checks. At the time of our inspection there was no registered manager in post. 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.

Staff had attended training in how to protect people from abuse and harm. However staff were not confident in describing how they would recognise potential signs of abuse and what processes they needed to follow to keep people safe. They said they would benefit from additional training in this area.

Staff did not have the necessary training to meet the individual needs of people at the service. One to one supervision sessions for staff were carried out, however staff had not received spot checks to observe their care practice, to support them to increase their performance and competence. Annual appraisals had not taken place, however they were scheduled to take place in 2015.

Staff were not able to describe the basic principles of the Mental Capacity Act (2005) (MCA) to ensure they supported people legally in line with their consent. Staff said they needed training to better understand the requirements of this legislation. The provider had scheduled staff training in MCA and DoLS on the 15 September 2015.

There was insufficient staff to meet people’s needs. There was not enough management hours allocated to support the effective operational running of the service. Whilst the provider had measures in place to recruit a new manager, deputy manager and additional nursing staff, this staffing arrangement was not in place at the time of our inspection.

A lack of adequate training in safeguarding adults; a lack of adequate training and staff support to meet people’s individual needs and a lack of sufficient staffing levels to meet people’s needs are breaches of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The provider had an improvement plan for the decoration and maintenance of the premises, however repairs we identified were not recorded on this plan. The acting manager said that it was difficult to change anything in the home as people often resisted change due to their health conditions. However, this should not prevent action being taken to make sure people remained safe.

Failure to ensure the environment is properly maintained to keep people safe is a breach of Regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The provider did not have a system for monitoring the cleanliness or maintaining effective infection control standards at the home. Where people had blood borne viruses or infectious diseases, there was no protocols in place to reduce the risk of infection to them and others. The provider had not adequately assessed infection control risks including those that are health care associated.

Peoples care plans were not consistently reviewed to reflect any changes in their care and treatment needs. Where the responsibility for people’s care and treatment was shared with other people to include health care professionals, reviews of care had not always taken place with their involvement, in a timely and formalised way. Care reviews did not take into account preventative measures to ensure the health, safety and welfare of people.

The failure to provide safe care and treatment; to protect people from harm by ensuring the premises are safe; to assess the risks of infections, protect people from these risks and provide a clean and hygienic environment which is properly maintained are breaches of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People’s individual risk assessments included measures to reduce identified risks and guidance for staff to follow to make sure people were protected from harm. Although risk assessments were in place they were not always up-to-date. People could not be assured that risks would be managed appropriately due to a lack updated records.

Audits were completed, however they did not adequately identify how the service could improve. The provider had not always identified all shortfalls or acted on the results of audits to make necessary changes to improve the quality of the service and care for people.

The service sought people’s feedback, comments and suggestions. However, the provider had not explored accessible means of obtaining people’s feedback. The provider had not analysed the results of any feedback given by people and acted upon this to improve the service.

Accidents and incidents were recorded, however they had not been monitored or analysed to identify how the risks of re-occurrence could be reduced to keep people safe.

Failure to adequately assess, monitor and improve the quality of the service, to include people’s views of the service, and the failure to ensure risk assessments records are up-to-date are breaches of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Staff did not know each person well or understand how to meet their support needs. Each person’s needs and personal preferences had been assessed before they moved into the service, however, staff did not always have accurate knowledge to provide person centred, consistent care.

People’s care plans did not take into account or monitor progress with people’s longer term goals and objectives. Where people had expressed a preference to move on from the service, this had not been assessed to support those people to work towards meeting their goals where possible.

There were insufficient activities for people to engage in at the service. The acting manager and activities co-ordinator tried to involve people in the planning of activities. They said that it was difficult to engage people in activities. Some people were able to go out independently.

Failure to provide person centred care and treatment to meet people’s needs, to include activities and failure to provide care or treatment designed with a view to achieving people’s preferences are breaches of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The provider had not notified the Care Quality Commission of all significant events that affected people or the service. We brought this to the attention of the provider and they implemented training sessions for the acting manager to update their knowledge in this area. It was too soon to evidence whether there was an improvement in this area.

Failure to notify CQC of significant events at the service is a breach of Regulation 18 of The Care Quality Commission (Registration) Regulations 2009.

Most staff treated people with kindness and respect. However, we observed one incident where a staff member spoke with someone in a way which was not compassionate or caring and did not promote their dignity. The acting manager was concerned to hear about this and said they would act swiftly to address this. Not everyone was satisfied about how their care and treatment was delivered.

We have made a recommendation about training for staff in providing care and support to people with dignity and compassion.

Information about how to access advocacy services was not provided in a clear and accessible way to all people. There was no information on activities available to people. Menus and satisfaction surveys were provided for people in a suitable format.

We have made a recommendation that the provider explores different ways of giving people information about services available to them in accessible formats and supports people to access these services.

Information leaflets were available to inform people about the complaints procedure. However these were not always provided in an accessible format. People were not always aware of how to make a complaint. No complaint had been received in the last 12 months before this inspection.

We have made a recommendation about giving people information about how to make a complaint in accessible formats and supporting people to make a complaint when required.

Not everyone had their cultural and spiritual needs met.

We have made a recommendation that the provider reviews and supports people to meet their diverse care, cultural and spiritual needs.

There were safe recruitment procedures in place which included the checking of references.

Accidents and incidents were recorded and although there was no system to analyse these to look for patterns or trends individually, control measures were put in place to reduce risks to people. All fire protection equipment was serviced and maintained.

Medicines were stored, administered, recorded and disposed of safely and correctly. Staff were trained in the safe administration of medicines and kept relevant records that were accurate.

The Care Quality Commission (CQC) is required by law to monitor the operation of Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Where people required a DoLS the acting manager had completed DoLS applications appropriately. They understood when an application should be made and how to submit one.

The service provided meals that were in sufficient quantity, well balanced and met people’s needs and choices. Staff knew about and provided for people’s dietary preferences and restrictions.

The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special Measures’ by CQC. The purpose of special measures is to:

Ensure that providers found to be providing inadequate care significantly improve.

Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

Services placed in special measures will be inspected again within six months. The service will be kept under review and if needed could be escalated to urgent enforcement action.