Kings Hill improved out of Special Measures from Inadequate to Requires Improvement, but continuing breaches were found in medicines management (including unaddressed emollient fire risk), staff recruitment, and governance, alongside no registered manager in post. Care planning, infection control and the caring domain had improved, but the provider remained reactive rather than proactive in driving service improvements.
Concerns (14)
criticalMedication management: “the provider had failed to ensure there were safe and consistent systems for the management of medicines which put people at risk of harm”
criticalMedication management: “Steps had not been taken to reduce the potential fire risk for people who used emollient creams. This was despite this risk being highlighted to the provider at our last inspection.”
criticalOther: “The provider had failed to establish and operate effective recruitment procedures.”
criticalGovernance: “There were ineffective systems to assess, monitor and improve the quality and safety of the service.”
criticalLeadership: “The provider had failed to have a registered manager in post for the carrying on of the regulated activity of personal care.”
criticalSafeguarding: “The provider told us there were no safeguarding concerns. However, the local authority safeguarding team confirmed there was a safeguarding investigation which they had spoken with the provider about.”
criticalRecord keeping: “The provider had failed to keep information about the staff they employed at the service.”
moderateStaff competency: “staff carrying out these checks continued not to have training at a high level to ensure they had the skills and knowledge to recognise potential errors”
moderateLeadership: “the appointed nominated individual was not involved in the management of the service”
moderateSupervision / appraisal: “Spot checks had only been carried out for the senior staff and not the other care staff member to ensure they were providing care to the required standard.”
moderateStaff training: “although staff had used equipment to help mobilise one person, they had only received on-line moving and handling training”
moderateIncident learning: “there was no evidence that they reviewed people's daily notes and incident reports to ensure staff had taken timely and appropriate action”
minorEnd-of-life care: “there was no evidence that the provider had spoken to people about their wishes at the end of their lives”
minorConsent / capacity: “the provider did not have a copy of appointee authorisations... At this inspection, the provider had not obtained a copy.”
Strengths
· Improvements made to person-centred care plans containing individual information about people's likes, dislikes and personal histories
· Staff treated people with dignity and respect; people reported being happy with their care
· Good communication between staff, family and friends ensuring continuity of care
· New risk assessment tool in place to identify and assess risks to people's care
· Improvements in infection control with staff trained in PPE and covid-19 procedures
Quality-Statement breakdown (24)
safe: Using medicines safelyNot rated
safe: Staffing and recruitmentNot rated
safe: Assessing risk, safety monitoring and managementNot rated
safe: Learning lessons when things go wrongNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Preventing and controlling infectionNot rated
effective: Supporting people to live healthier lives, access healthcare services and supportNot rated
effective: Staff support: induction, training, skills and experienceNot rated
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
effective: Supporting people to eat and drink enough to maintain a balanced dietNot rated
caring: Respecting and promoting people's privacy, dignity and independenceNot rated
caring: Ensuring people are well treated and supported; equality and diversityNot rated
caring: Supporting people to express their views and be involved in making decisions about their careNot rated
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesNot rated
responsive: End of life care and supportNot rated
responsive: Improving care quality in response to complaints or concernsNot rated
responsive: Meeting people's communication needsNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsNot rated
well-led: Continuous learning and improving careNot rated
well-led: Engaging and involving people using the service, the public and staffNot rated
well-led: Duty of candourNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated
well-led: Working in partnership with othersNot rated
Kings Hill was rated Inadequate overall and placed in special measures due to widespread shortfalls in leadership, governance, risk management, medicines, recruitment and person-centred care, with multiple continued breaches of regulations. The service had no registered manager, the provider lacked oversight, staff were working without proper checks, and a safeguarding referral was made when CQC could not contact the provider for four days.
Concerns (14)
criticalGovernance: “Quality monitoring systems continued to be insufficient to identify shortfalls and drive continuous improvement in the service.”
criticalLeadership: “There continued to be no registered manager, the nominated individual was absent, and it was unclear who was managing the service in their absence.”
criticalMedication management: “There were not safe and consistent systems for the management of medicines which put people at risk of harm.”
criticalStaff competency: “These competency checks had not been undertaken at the last inspection... we only received a competency check for one staff member.”
criticalStaffing levels: “The provider had no oversight of staff deployment to ensure staffing was kept at safe levels as they did not have access to the staffing rota.”
criticalSafeguarding: “we sent a safeguarding referral to the local authority as we were concerned about people's safety. The provider did not contact us until the afternoon of 29th January.”
criticalIncident learning: “The provider told us they were not aware of the incident. This person had also sustained a small cut to their upper lip on 16 January. No accident or incident form had been completed”
criticalPerson-centred care: “People did not consistently receive personalised care that met their needs. This was a continued breach of regulation 9 (Person centred care)”
criticalRecord keeping: “Records relating to people's care and support were not accessible... A number of records used by the provider to monitor people's care and treatment had not been completed.”
criticalOther: “Two staff members who had started their induction did not receive their DBS checks until several months after they had begun working.”
moderateCare planning: “there was no guidance for staff as to what may trigger these behaviours or how to best support the person to keep them and staff safe.”
moderateStaff training: “it was not possible to concur all staff had been trained as there was not a definitive list of staff who supported people.”
moderateConsent / capacity: “There was no evidence people had been consulted or their mental capacity assessed to evaluate potential risks and so take action to keep people safe.”
minorComplaints handling: “The provider was not able to provide any evidence these sessions were taking place.”
Strengths
· A relative said they trusted staff and felt their family member was safe and would recommend the service.
· Personal protective equipment, such as gloves, aprons, face masks and hand gel were available in people's homes.
· Easy read versions of documents including service user guide, complaints procedure and care plans were available to support communication needs.
· Staff knew people well and said the staff team worked well together and the provider was easily contactable for advice and support.
· The service continued to work in partnership with health professionals and supported people to attend healthcare appointments.
Quality-Statement breakdown (15)
safe: Assessing risk, safety monitoring and managementInadequate
safe: Using medicines safelyInadequate
safe: Learning lessons when things go wrongInadequate
safe: Staffing and recruitmentInadequate
safe: Systems and processes to safeguard people from the risk of abuseInadequate
safe: Preventing and controlling infectionRequires improvement
responsive: Planning personalised care to ensure people have choice and controlRequires improvement
responsive: End of life care and supportRequires improvement