King Charles 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 69 (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.

Accidents and incidents were documented and reviewed by the registered manager to identify any areas of improvement or learning.

Daily meetings took place to discuss people's needs. Any changes or incidents that may have occurred were discussed to ensure all staff were up to date.

The first day of inspection we identified some areas for improvement in the environment and medicines. The registered manager immediately reviewed these issues, held a staff meeting and produced an action plan to address them. This evidenced the openness of the registered manager to learn from issues identified and take immediate action.

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.

The service communicated with external agencies to help ensure continuity of care. For example, there was key information available for ambulance crews, paramedics and hospital staff if people needed to be admitted to hospital unexpectedly.

People, their relatives, and other professionals were involved in planning people’s care and support needs.

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.
People were relaxed and comfortable in the service and enjoyed spending time with the staff team. A person commented, “I am safe here; I am looked after by fabulous and kind staff’.”
Relatives and external professionals told us they had no concerns relating to safeguarding.
Staff had completed safeguarding training and were confident about the processes to follow if they had any safeguarding concerns.
The registered manager had a good understand of local safeguarding processes and necessary contact information was readily available if needed.
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). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). 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.
People’s capacity to make decision had been appropriately assessed. Where appropriate DoLS applications had been made and conditions complied with. Where the service made decisions on behalf of individuals who lacked capacity these decisions had been consistently made in the person’s best interests.

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.

Risks were identified and mitigated effectively. People’s care plan’s included clear guidance for staff on how to protect people from identified risks.
People had individual risk assessments relating to the care and support they received. These included risks relating to eating and drinking, moving and handling, skin integrity and falls. Personal Emergency Evacuation Plans (PEEPs) had been developed to inform first responders and staff of the support people would need in the event of an emergency.

The provider did not always detect and control potential risks in the environment. Although risks in people's rooms and communal areas had been effectively managed, some risks in the operational and staff areas had not been effectively managed.

On the first inspection visit some environmental issues were identified, for example flooring in the cleaning cupboard was damaged and needed replacing to prevent infection risks, fan ventilators needed cleaning and a wall needed treatment. On the second visit the registered manager had ensured that all the issues identified had been actioned; new flooring had been laid in the cleaning cupboard, treatment and repair of the wall completed, a microwave had been replaced and fans cleaned. The registered manager then implemented an environmental audit and action plan to enable them to identify any issues in their monthly audit and take remedial action.

Necessary checks had been completed to ensure the safety of the service’s environment and utilities by appropriately skilled contractors. Firefighting equipment was available if required.
People’s bedrooms were decorated in accordance with people’s individual tastes and interests.

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.
The service was well staffed, and rotas showed planned staffing levels were routinely achieved. The registered manager had recently recruited nurses and care staff and had no current vacancies.
Staff understood their roles and responsibilities and were positive about how they supported each other and worked as a team. New nurses to the team commented, “I have never worked where nurses don’t need to do personal care as the carers do it, they are fabulous, so skilled and caring, they are a happy team."
Staff were flexible and would cover additional shifts if needed so that people received consistent care from people they knew. A staff member commented, “Staff get breaks and work their contracted hours - if you want to pick up extra you can but it is monitored as they (managers) don’t want us to tire ourselves out.”
Staff were positive about the support they received out of office hours as they had a ‘on call’ system. Staff said that on call managers responded to their queries.
Staff received support through observations, supervisions and appraisals with their team leaders. This gave them the opportunity to discuss their role, concerns and training needs as well as personal welfare. Staff told us they felt well supported by their leaders.
Prospective staff went through a safe recruitment process which included their right to work in the UK and their fitness for the role. All staff had undergone a Disclosure and Barring Service (DBS) check to help ensure they were suitable to work in the care sector.
All staff completed training relevant to their role. Training included a mixture of e learning, in house and external courses. A member of staff told us, “There’s a lot of training.”

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.

The environment was clean and tidy. Cleaning schedules showed daily, monthly and deep cleans were completed throughout the service. The kitchen was clean and had a food hygiene rating of 5. Daily checks of fridge and freezer temperatures were completed. There was an up-to-date policy on the control of infection, prevention and control (IPC) which staff could refer to if needed.
Staff had access to personal protective equipment (PPE) to use when carrying out personal care.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.
On the first day of inspection, it was identified people who were prescribed PRN medication (when required medicines) did not have a protocol available for staff to guide them as to when this medication should be taken. Following this the registered manager held meetings with all staff to discuss medication practices to ensure medicines were signed for appropriately and that systems were effective.
On the second day of inspection, PRN protocols had been implemented for all people in the service and attached to medication records for easy access. This meant nursing staff would know in what circumstances and when this medicine should be administered. Nursing staff were also recording why PRN was being administered and whether it had been effective.
No-one was prescribed medicines covertly. Covert medication is the administration of medicines in a disguised format without the person's knowledge or consent. This typically involves hiding medication in food or drink. We were told a GP had given permission for a person to have their medicines given covertly if needed. This was recorded in the persons notes but there was no record of the GP’s agreement. The registered manager confirmed with nursing staff covert medicines had not been administered to this person. They assured us evidence of agreement would be gained and recorded.
Medicines were stored securely and staff monitored temperatures of areas used to store medicines, to ensure they were kept within the recommended range. Medicines were managed by nursing staff who had received training and had their competency assessed.
Medicine audits were completed monthly. Medicines that required additional storage security, such as controlled drugs, were audited consistently.