Kingston House is registered to provide accommodation and personal care for up to 46 people. At the time of our inspection there were 42 people living at the service. Kingston House is divided into three sections, Primrose, Tulip, and Lavender Lodge. Primrose and Tulip are residential areas of the home, with shared lounges and a dining room. People living in Lavender Lodge have a diagnosis of dementia. Lavender Lodge was accessible through key coded secure doors. Lavender Lodge had a separate lounge and dining room, although the whole home came together for some activities.

This inspection was unannounced and took place over two days. The inspection commenced on 19 September 2018 and we returned 20 September 2018. We previously inspected the service in April 2017 and found three breaches of The Health and Social Care Act 2008. At this inspection we found two breaches in regulation, one of these was a repeated breach from the previous inspection.

At the previous inspection, in March 2017, we found the service to be in breach of three regulations. We found that there were not sufficient staff to meet people’s needs. Where people lacked the mental capacity to consent to care and treatment, decisions were not always made by someone with the appropriate legal authority. The quality and consistency of records meant that there was no overview of the support people received. People’s care plans did not reflect their care needs. Also, the systems in place to monitor the quality of the service failed to identify the shortfalls found during the inspection.

During this inspection, we found improvements had been made so that the service was no longer in breach of two regulations. There was appropriate mental capacity assessment documentation in place. Where people had representatives with Lasting Power of Attorney (LPoA), this was documented, with a copy kept on file. This meant the service knew who to contact in relation to decisions and the LPoA had the legal authority to act on the person’s behalf. There were also improvements in staffing and the service was fully staffed.

We found a continued breach of Regulation 17 of the Health and Social Care Act 2008, regarding good governance. This was because appropriate action had not been taken to address shortfalls in quality monitoring systems. There were areas of concern identified at the inspection that had not been recognised as part of the audit and monitoring checks completed by the management team. We also found breaches in Regulations 9 regarding person-centred care and 12 for safe management of risk.

Risks were identified where people could not use their call bell. However, there were no directions for staff around how they should reduce these risks.

Where people were prescribed creams and lotions, the protocols did not explain where and when staff should administer these. Record keeping for cream and lotion administration was not always completed, and did not evidence that people received their prescribed cream as directed.

Where accidents happened, these were recorded and monitored; however, body maps for injuries were not followed up. Where injuries had occurred, these were recorded, but there were no progress notes. We saw reference to a carer finding bruising on a person in the daily notes. There was no body map or accident form completed regarding this. Where one person had experienced frequent falls, the accident form stated in the management notes that a risk plan would be implemented. We saw that this had not been implemented following the accident.

Food and fluid intake monitoring for people who were at high risk of malnutrition and weight loss was not documented in a consistent manner. The recording system was not being used appropriately. This meant that there was no overview of how the service was meeting people’s identified needs with regards to their nutrition.

Record keeping around activities and social interactions varied in quality and consistency. Th

Kingston House is registered to provide accommodation and personal care for up to 46 people. There were 42 people living in the home on the day of the visit and one person was in hospital. The home is divided into three areas, Primrose, Tulip and Lavender lodge. Lavender lodge was an addition to the original building and supported people who had a diagnosis of dementia. The inspection was unannounced and took place on 27and 28 March and 3 April 2017.

A registered manager was in post when we inspected the service and was available and approachable throughout our inspection. 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 previous inspection the home received a rating of good overall and a rating of outstanding in the responsive domain. At this inspection we found areas requiring improvement which was not consistent with the previously awarded rating.

There were sufficient staff to meet people’s basic care needs. However there was not always enough staff available to meet the high level of social and emotional needs present in the dementia unit of the home. During our inspection we observed incidents that were not effectively managed due to a lack of available staff.

The home had risk assessments in place; however they were not always in place for all identified risks to people. We found that risks for individual people would sometimes be mentioned across several care plans instead of one overarching risk assessment being in place. Different actions would also be recorded for managing the same risks. We observed that at times people experienced anxiety and needed reassurance from staff. Although staff responded appropriately to people at these times, the recording of how to manage these situations was not always in place to ensure consistency.

There was often inconsistent or conflicting information in people’s care plans and monitoring records which made it hard to ascertain a person's most current needs.

Although quality assurance systems were in place to monitor the running of the home, these had not picked up all of the shortfalls identified at this inspection in order to address and take the necessary action.

Staff were not given opportunities to meet the requirements of their role. Staff had not always been given the opportunity to renew their training within the provider set timescales to ensure they maintained their skills and knowledge. We saw that medicines training had expired for four staff and not been renewed. We observed one of these staff continuing to administer medicines during our inspection.

The home had not always obtained the appropriate consent before taking decisions on behalf of people to ensure care was given in line with their preferences. One person had a sensor mat in place to alert staff when they moved around their bedroom but there was no consent to show their agreement or assessment of their capacity to take this decision.

People felt safe living at Kingston House and the comment form one person included, “I feel really safe being with other people in the home and living in a nice area. If I need help I am confident the staff would respond as I have seen them respond to others if they needed help or medical support.” Staff had the knowledge and confidence to identify safeguarding of abuse concerns and knew to act on them to protect people.

We observed staff responding to people respectfully and engaging people in positive interactions including singing and chatting. One person told us “I like living here, we have things here we can do and look at.”

The registered manager promoted a positive culture and was a visible presence around the home supporting people and staff when needed. People

On entering Kingston House we found the atmosphere to be warm and welcoming. We spoke with people who used the service, and staff as well as observing staffs understanding of the care and support needed. The people who used the service we spoke with said that staff were "pretty good" and "really kind." We noted people's rooms were decorated with their personal belongings.

We looked at people's individual files which incorporated their personal profile, care plans and risk assessments and found they encompassed the safety and well-being of people who used the service. People told us that they knew how to raise a concern or complaint and felt confident in doing so. They said if they had any issues or concerns they could "talk to the

manager." There were policies and procedures in place providing guidance and all staff had received relevant training courses which were identified on the training schedule. Staff told us they were supported by management and that they had received regular training, supervision and appraisals.

We looked at the cleanliness and infection control procedures and the management of medicines and found the provider had adequate systems in place to ensure the safety of the people who used the service regarding the control of substances hazardous to health and the administration of medicines.

We spoke with five of the 45 people who lived at the home about the meals served. The five people we asked made the following comments “ the meals are ok, there is always a choice of two meals,” “There is always fruit and fresh flowers on the tables,” “We had a residents meeting with the cook three weeks ago about the menus and we asked for fish pie.” “We are weighed weekly by our key worker.”

We observed the way staff helped people during the lunchtime meal. We saw staff speak to people at eye level and asked them to make a choice of dessert and drink. Staff used a gentle, but professional approach when they spoke to people. The care plans we read showed people’s dietary needs, including diabetic, vegetarian and fortified diets were met.

On the day of the inspection malnutrition screening tool (MUST) training was being delivered to staff. This training was to help staff assess people at risk of weight loss. The records showed people’s food and fluid intake was monitored where they had been assessed as being at risk of weight loss. Staff needed to ensure they were being consistent in how they recorded people’s food and fluid intake.

The cook was taking steps to ensure people had a say about the meals served and sought their preferences about the way their meals were presented.

We carried out a planned inspection of Kingston House care home in January 21012. At this inspection we found there were outcomes which did not meet compliance and asked the provider to make improvements. We visited the home on 9 August 2012 to check that the improvements had been made.

We saw the staff engaged with people and used a gentle and respectful approach. People were offered choices and given time to make decisions. We saw staff used correct moving and handling techniques to support people with their mobility needs.

We spoke with two families and they told us there was a programme of activities such as bingo, quizzes and outings. We were told there were one-to-one activities, festivals and that special events were celebrated, for example, Easter, The Olympics and The Jubilee.

The provider had taken steps to ensure the environment was adequately maintained and there were systems in place to monitor the quality of the service.

People who live in the Primrose and Tulip Lodges said they felt involved in their care and able to make decisions. A relative who was visiting said that they were happy with the care given and thought the staff were very dedicated and caring. People told us that staff were very respectful and kind. We observed that staff knocked on doors before entering people’s rooms. We saw that staff took the time to engage with people and used communication methods which would help people to make decisions.

A relative told us that they thought the home was clean and tidy and a happy place to visit. Another relative said they liked the home because it had a calm, gentle atmosphere. One person asked us to have a look at their room, which they described as being ‘really comfortable with their things, just so’. People told us they felt very safe within the home.

Out of the 14 people we spoke with, nine said that there were not enough activities, but thought this would improve when the new activities co-ordinator started. People said that they received good care but three people thought that sometimes it took too long for the call bell to be answered.

People living in the home and their relatives told us that they were encouraged to express their views regarding the services provided at Kingston House. People said that the manager and the staff were very open to talking about complaints and that they would talk to them directly.

This was an unannounced inspection which took place on 19 November 2014.

Kingston House is registered to provide care (without nursing) for up to 46 people. There were 46 people resident on the day of the visit. The home is divided into two areas with a separate area for people living with dementia. The home is purpose built over two floors. People have their own bedrooms with en-suite facilities. There are spacious shared areas within the home and gardens.

There is a registered manager running the service. 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.

People told us that they felt safe in the home. One person described it as: ‘‘as safe as houses’’. Care workers were trained in and understood how to protect people in their care from harm or abuse. People told us they had every confidence in the manager.

The home had enough staff to keep people safe and a recruitment process which was designed to ensure the staff they employed were suitable and safe to work there. Care staff had built strong relationships with people who lived in the home. Staff members had good knowledge of people and their needs. The staff team were well supported by the management team to ensure they were able to offer good quality care to people.

People were given their medicines in the right amounts at the right times. The home took all health and safety issues seriously to ensure people were kept as safe as possible. The home looked at any accidents and incidents and learnt from them. They tried to ensure they did not happen again, if possible.

The service understood the relevance of the Mental Capacity Act 2005, Deprivation of Liberty Safeguards (DoLS) and consent issues which related to the people in their care. The Mental Capacity Act 2005 legislation provides a legal framework that sets out how to act to support people who do not have capacity to make a specific decision. DoLS provide a lawful way to deprive someone of their liberty, provided it is in their own best interests or is necessary to keep them from harm. They had taken any necessary action to ensure they were working in a way which recognised and maintained people’s rights.

People were supported to contact GPs and other health professionals when necessary. People told us they were provided with very good health care. The home sought guidance from health care specialists when required. People were offered good quality and nutritious food which they described as: ‘‘lovely’’.

The service provided people with activities designed to encourage their participation and enhance their lifestyle. People were treated as individuals and their choices and wishes were respected. Treating people with dignity and respect was a key feature of the home. Those people who were able were encouraged to maintain their independence for as long as possible. The home was an integral part of the community and had developed strong community ties.

People, staff and other professionals told us the home was managed very well. They said there was an open and positive culture and everyone felt valued. The registered manager and staff team worked closely with specialist organisations to ensure they were up-to-date with good practice and knew how best to offer care to people. They had ways of making sure they kept the quality of care they offered to a high standard.