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 identifi