Kitwood House Care Residence Also known as 1-11337159380

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

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 changed to inadequate. This meant people were not safe and protected from avoidable harm. The provider was in breach of the legal regulation relating to safe care and treatment.

This service scored 38 (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 did not always have a proactive and positive culture of safety based on openness and honesty. For example, where there were incidents involving people requiring physical restraint or people sustaining unexplained bruising, suitable investigations were not always undertaken to establish how, when and why they occurred. This meant there was limited evidence that any lessons learnt were shared with the staff team to embed good practice in order to prevent further similar incidents from occurring.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. We did find referrals were not always made to relevant agencies in support of people’s needs as highlighted in the medicines optimisation quality statement when the use of people’s ‘when required’ medicines were being used frequently a review of their medication was not always requested from the GP to ensure these increases were safe and suitable. Relatives were involved during the transition stage when people moved into the service.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. Where incidents had taken place, they were not always thoroughly investigated to identify steps to prevent further incidents. Not all people who had been restrained following an incident of behaviours that may challenge, were given the opportunity for a debrief. The service’s policy recognises the need for a debrief and the importance of engaging people in the process. However, there was no evidence where a person was unable to verbally communicate their needs, additional steps had been taken, for example utilising visual aids or simplified language. For some people the relevant safeguards were not in place, this included the Mental Capacity Act (MCA) not being followed, the MCA is in place to promote and safeguard decisions within a legal framework.

Staff spoken with were familiar with adult safeguarding policies and procedures.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Although some risk assessments were in place in respect of people’s health and wellbeing, not all of their needs and risk had been properly assessed. This included people’s physical health needs. Some risk assessments were not accurate or up to date. Where risks had been identified, guidance on how to mitigate these risks was not always in place for staff to follow in order to prevent avoidable harm. When people became anxious or distressed, there were no supportive systems in place to help staff identify the reasons for their distress so that appropriate person centred solutions could be provided. This was especially concerning for people who were unable to verbally communicate as there were no systems in place to support them to communicate in alternative ways. For example, by using picture cards or talking mats. Talking mats is a tool that uses pictures or symbols to help people communicate. Staff who were new to the service or who were agency staff were not always aware of the needs of the people they were supporting. This placed people at risk of inappropriate or unsafe care.

The provider did not always detect and control potential risks in the care environment. During day 1 of the inspection, we identified there was not enough evacuation chairs to evacuate people to a place of safety in the event of an emergency. This was discussed with the provider and registered manager and by day 2 this had been rectified. The environment on some units was noisy. We saw incident records showed the cause of some people’s distress was due to this type of environment. There was little evidence however, the impact of this type of environment on their emotional wellbeing had been considered or addressed. The provider had not fully considered the compatibility of people living together. This meant there were people living there who inadvertently behaved in ways which other people found difficult to cope with, this was evidenced through review of incidents and accidents. This put people's mental health and well-being at risk. The service was decorated and adapted to meet the needs of people living there.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

Relatives and staff told us they did not think staffing levels were always sufficient to meet people’s needs. For example, a relative told us, “At times there are not enough staff, I mentioned it to [registered manager] and was told it was at the required level. It’s a bug bear at times’ Its difficult to get a drink or a tissue.” A staff member told us, “I feel the dependency of individuals needs to be looked at with ratio, we tell head office we are short staffed, and they say no you have the right ratio” and “I love my job and enjoy working here although it is extremely hard, just need more staff.”

We observed staff did not have time to support, comfort or reassure people who became distressed. People sometimes had a long wait for staff to support them with personal care or at mealtimes, because there were not enough staff on duty to meet their needs promptly.

Safe recruitment processes were in place.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading. We identified areas within the service that required cleaning, some worktops, door handles, banisters where sticky and dirty. We identified feaces on the floor in one unit. One of the bathroom toilet seats was also significantly stained with urine. This was raised with the registered manager and provider on day 1 and we saw the toilet seat had been replaced by day 2. There were cleaning schedules in place however, some areas still required cleaning. One relative told us, “It's lovely and clean.”

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Some people needed medicines to be hidden in food or drinks, covertly. There was no information available, from a pharmacist, for staff to follow as to the safest way to disguise each individual medicine. This was discussed with the registered manager and provider who told us they had sought support in relation to covert medicines however the guidance had not been provided. The protocols to support the safe administration of these medicines were either not in place or were not personalised, and there was lack of information for staff to follow to assist them to decide the most appropriate dose to administer when there was a choice of dose. This meant people may not get their medicines consistently and at the time they were needed. Steps were implemented to ensure pharmacist advice was sought. The effectiveness of this will be explored during our next inspection. Nursing staff had, had their competencies assessed in relation to medicine management however care staff who were responsible for applying topical creams had not been assessed as competent.