Kirkstall Court

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.

The service demonstrated a generally positive learning culture where staff and leaders acted on identified concerns. Managers reviewed incidents, including falls and safeguarding events, and took appropriate action such as updating risk plans and seeking professional advice where required. For example, where people had had several falls, staff involved the falls team, occupational therapists and GPs to help reduce risks. Staff described the registered manager was responsive and supportive, with professionals noting that staff were receptive to advice and acted on it promptly. Lessons learned were recorded; however, we found instances where the analysis of incidents lacked sufficient detail to support consistent organisational learning.

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 moving into the service experienced appropriate assessment and coordination with external agencies. People’s needs were assessed prior to them moving to the service, with involvement from hospital teams, GPs and social workers. Information about new people moving to the home was shared with staff through handovers and daily huddles.

Relatives described smooth transitions, with management providing information and supporting families through the process. One relative said the process was “really good” and reduced pressure on them.

Staff ensured continuity when people moved between services. They responded promptly when people were admitted to hospital, sharing relevant information as needed.

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 had completed safeguarding training and understood safeguarding responsibilities. Relevant policies and procedures were in place. Concerns were reported and appropriate actions taken, including contacting the local authority, police and relevant professionals when required.

Where people had restrictions on their liberty, the provider had sought appropriate legal authorisations.

Relatives told us they felt able to raise concerns. One commented that if they were worried, “I would go straight to the manager.”

Healthcare professionals confirmed they had no safeguarding concerns and staff were receptive and cooperative.

People were generally supported to manage risks, but there were some gaps in documentation and improvement was required in record keeping relating to risk management. We found some risk assessments lacked essential detail for staff, such as safe blood‑sugar ranges for a person with diabetes. Staff were knowledgeable about people’s needs and we did not find evidence that these recording issues were having a negative impact on the care people were receiving. We discussed these issues with the registered manager, and they took immediate action to address the concerns. They also explained the further action they planned to take to monitor this moving forwards.

We also observed some good practice around risk management, which included frequent monitoring for those at risk of falls and appropriate referrals to specialists.

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 environment was generally safe, clean and appropriately maintained. We observed clean communal areas, safe access to outdoor space and appropriate equipment in use, including hoists and call bells.

Fire safety arrangements were effective.

Relatives confirmed the environment felt safe and staff were present to support people when 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.

Staffing levels were generally appropriate. The provider used a dependency tool to assess staffing requirements, and agency staff were used only where people required 1:1 support. Some relatives reported delays when phoning the service.

Staff were safely recruited with required checks in place.

Training compliance was mostly good, although additional training was still being arranged relating to support of people with a brain injury.

Staff on shift demonstrated caring and patient interactions, and relatives said staff were “very good” and supportive.

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.

Infection prevention and control practices were safe. We observed a clean environment and appropriate personal protective equipment was used during care tasks. Domestic staff had clear cleaning schedules and completed regular checks across all areas of the service.

People and relatives reported that the home was “always clean,” with only occasional isolated issues.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

We found some aspects of medicines management were not always managed safely.

Stock records were not consistently accurate, and we found discrepancies between recorded and actual stock levels. One person was receiving their medicines in a crushed form; however, there was no documented evidence that this had been discussed with, or authorised by, the person’s GP to ensure it was safe and appropriate to do this. Records relating to the administration of thickening agents were not consistently completed, and topical medicine records, including creams and emollients, were not always maintained in line with best practice. We raised these issues with the registered manager. During our second visit, we found actions had been taken and there were improvements in several of these areas.