Kathryn's House

On this page

• 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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has remained good.

This meant people were safe and protected from avoidable harm.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Leaders demonstrated a positive approach to learning and improvement. Falls analysis and root cause analysis were completed following incidents, helping to identify contributing factors, trends, and opportunities to reduce the risk of recurrence. For example, following an unwitnessed fall for 1 person, the service completed a detailed root cause analysis. This identified discrepancies between incident records, night-time monitoring logs and staff accounts, as well as gaps in risk assessment and monitoring arrangements. Learning from the investigation led to targeted staff coaching, improved guidance on accurate record keeping, enhanced checks for people at risk of falls, and updates to care planning and falls risk assessments. Leaders also reviewed the suitability of monitoring equipment to better manage identified risks.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

People’s needs were assessed before they moved into the service to help ensure staff could meet their care and support needs safely. Leaders completed a pre-admission assessment and also considered assessments provided by the funding authority when determining whether they could support people appropriately. However, we found the provider’s own assessment documentation lacked some detail and could provide a more comprehensive overview of people’s needs and associated risks. We fed this back to the manager during the assessment, who acknowledged this and told us they would review and strengthen the assessment process to ensure more detailed information is captured prior to admission.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Staff received safeguarding training and understood their responsibilities to recognise, respond to and report concerns. One member of staff said, “If I am working as a carer [and observed a concern], I would tell my team lead or senior, or manager. [If needed] I would report to police, CQC, Surrey County Council. I would not have any worries doing this. [The manager] would definitely take it seriously and act to put it right.”

Leaders maintained oversight of safeguarding incidents and worked with relevant agencies when concerns were identified. Records demonstrated safeguarding matters were appropriately reported, investigated and followed up, with learning shared to help reduce the risk of similar incidents occurring. For example, following an incident where a person became physically aggressive towards another person, the service completed a detailed root cause analysis to understand the factors that contributed to the event. As a result, the manager implemented a range of actions including enhanced supervision, review and update of care plans and behaviour support strategies, referrals to relevant healthcare professionals, and ongoing monitoring of risks.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA, whether appropriate legal authorisations were in place when needed to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met.

We found leaders ensured the legislation was complied with as some people were subjected to restrictions without the appropriate legal authorisation. Where restrictions were in place, for example in relation to sensor mats and locked doors, there were appropriate capacity assessments and best interest decisions in place.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We reviewed the management of risks associated with constipation and found effective systems were in place to support people at risk. Bowel monitoring records were maintained, and staff were able to identify when concerns required escalation or intervention. Care plans provided guidance on the support people needed, and records demonstrated appropriate action was taken when changes in bowel habits were identified. Staff understood their responsibilities in monitoring bowel health and were aware of the actions required to reduce the risk of constipation and associated complications. One member of staff said, “Some people are independent with toileting, so we ask them every day if they have had their bowels open, they do speak to us and tell us. We record this on our handset and on the handover sheet. We have a warning alert on our system if a person has not had their bowels open for 3 days it will alert us.”

Other risks associated with people’s care and support were appropriately assessed and managed. We reviewed a range of risk assessments, including those relating to choking, falls, skin integrity, oral health and mobility, and found these reflected people’s individual needs and identified the actions staff should take to minimise risks. Where people were at increased risk, there was clear guidance in place to support consistent care and promote positive outcomes. One person told us, “They are now very watchful in the dining room and stand next to me and now because of this I feel safe.”

Staff demonstrated a good understanding of the risks relevant to the people they supported and were able to describe the measures in place to keep people safe while maintaining their independence and wellbeing. One member of staff told us, “We have people who have a modified diet, we check their care plans, so we know what they need. We have enough information in their care plans; this tells us what the residents like and how they do things.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The service provided people with a safe and well-maintained environment. Regular health and safety checks were completed to monitor the safety of the premises, equipment and systems within the home, and action was taken when issues were identified. Environmental risks were assessed and reviewed to help ensure people, visitors and staff remained safe.

Personal Emergency Evacuation Plans (PEEPs) were in place and provided clear guidance on the support people would require in the event of an emergency, helping to ensure staff could respond effectively and people could be evacuated safely if needed.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

During our assessment, we observed there were sufficient numbers of staff deployed during the day to meet people's needs and provide timely support. One person told us, “I very rarely use my buzzer, but I did use it once at night and they certainly came extremely quickly.”

Staff were visible throughout the service and responded appropriately to people's requests for assistance. However, we fed back to the management team a concern that only 2 staff members were routinely deployed at night. This was despite people walking around the service during the night and others requiring the support of 2 staff for repositioning. The manager acknowledged this feedback and told us they were reviewing night-time staffing levels to ensure staffing arrangements continued to meet people's needs safely and effectively.

Staff received regular training and supervision to support their professional development and enable them to reflect on their practice. Records showed supervision sessions took place at planned intervals and covered a range of topics, including performance, training, wellbeing and people's care needs. Staff told us they felt supported by managers and were able to discuss any concerns or development needs. These arrangements helped to ensure staff remained competent, supported and able to provide safe, effective care. One member of staff said, “They will provide us with training and they are always looking for new training for us.”

Robust recruitment processes were in place to help ensure suitable staff were employed to support people safely. We reviewed recruitment records and found appropriate pre-employment checks had been completed, including proof of identity, employment history, references and Disclosure and Barring Service (DBS) checks. A DBS check is an official criminal record check used to vet job applicants and volunteers.

The provider also maintained profiles and compliance information for agency staff, which enabled them to assure themselves that agency workers had the necessary skills, experience and required checks in place before working at the service.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

We identified a small number of environmental issues, including one bedroom that had a noticeable odour of urine, a dirty toilet brush in a bathroom, and thick cobwebs on a landing window. We brought these issues to the attention of the manager during the assessment, who took immediate action to address them.

However, overall, the service was clean, well-maintained and free from clutter, and we observed staff following good infection prevention and control (IPC) practices throughout the visit. One external professional told us, “I don’t have any concerns with IPC, I think they are really good with that here.”
 

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Arrangements for the administration of 'as required' (PRN) medicines were in place; however, some protocols would benefit from more personalised information to help ensure a consistent approach to administration. The manager was already reviewing and updating these documents at the time of our visit. They said, “We are trying to change our PRNs to make sure they have more information.”

However, medicines were managed safely, and appropriate systems were in place for the ordering, storage, administration and recording of medicines. One person told us, “I could always ask the staff if I needed paracetamol for a headache or whatever. They bring me all my medication that I take regularly.”

We reviewed a sample of medication records and found people received their medicines as prescribed. Medicines prescribed to be taken as and when required for mental health needs, including antipsychotic medicines, were appropriately managed, with evidence of monitoring and oversight.