Kenneth 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 people were protected from abuse and avoidable harm.

At our last assessment we rated this key questiongood. At thisassessmentthe rating hasremainedgood.

This meant people were safe and protected from avoidable harm.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Theprovider 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 continuallyidentifyand embed good practice.For example, accidents and incidentswerereviewed using theproviderslearningresponselevelsystem to ensureappropriate actionbased on risk and impact, including staff debriefs, safety huddles, and improvement plans whererequired. Incidentswereanalysed for themes and trends, with learning shared and embedded into practice. Actionswereagreed,monitored, and followed up to reduce the risk of recurrence, and incidentswerereported to relevant external agencies whererequired. Meetings supportedforward planning, including training, development, and upcoming events, ensuring staffweresupported to deliver safe,high‑qualitycare.

The provider worked with people and healthcare partners toestablishand maintain safe systems of care, in which safety was managed ormonitored.For example,each person hadanup‑to‑datehospital passport, care plans and risk assessments clearly reflectingcurrent professional adviceand guidance. These were updated promptly following healthcare appointments, changes in people’s health, or treatment reviews from GPs,dentistsand other healthcare services. When people moved between services or accessed hospital care and other healthcare appointments, relevant information was shared ina timelyandappropriate wayto support safe pathways and continuity of care.

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, avoidableharmand neglect. The provider shared concerns quickly and appropriately.For example, although there had not been any safeguarding concerns requiringescalation, the provider hadappropriate systemsin place to recognise and respond tosafeguarding concerns. Staff had completed safeguarding training anddemonstrateda good understanding of thedifferent typesand indicators of abuse, as well as the procedures for reporting concerns.

There was a clear safeguarding policy in place, which was regularly discussed during team meetings to ensure staff remained aware of theirsafeguardingresponsibilities.

The provider worked with people to understand and manage risks in aperson‑centredway. Staff provided care that was safe and supportive, while enabling people to take part in activities that mattered to them.For example, records reviewed showed,person‑centredrisk assessments and care plans were in place and readily available to staff. These clearlyidentifiedrisks and outlinedappropriate supportstrategies, enabling staff to manage risks safely while promoting choice and independence. People were involved in discussions about their risks wherever possible, and plans were reviewed and updated to reflect changing needs.One staff member told us,“People are involved in discussions about their risks wherever possible, so they understand them and can make choices, with the right support in place.”

The provider did not always effectivelyidentifyand manage risks within the care environment or ensure equipment, facilities and systems consistently supported safe care. For example, some areas of the home showed signs of wear and tearwhich presentedriskto people. Thisincludeduneven flooring and areas requiring redecoration. In addition, parts of the environment were notmaintainedto a clean standard, and weobserveddirty shower heads and unclean bathroom cabinets. These concerns were escalated to theregisteredmanager.

However, theregisteredmanager responded promptly anddemonstrateda proactive approach to improvement. On the second day of the inspection, action had been taken to address the issuesidentified. Shower heads had been replaced, bathroom cabinets had been cleaned, and new cabinets had been ordered as part of an ongoing improvement plan to enhance environmental safety and reduce risks.

In addition, there were strong systems in place in other areas of safety. Theproviderhad an up-to-date fire risk assessment, and all staff had received fire safety training anddemonstrateda clear understanding of emergency procedures. Health and safety checks were completed regularly and theregisteredmanagermaintainedoversight of servicing schedules, maintenancerecordsand statutory certificates.

The provider ensured there were sufficient qualified, skilled, and experienced staff who received effective support, supervision, and development. Staff worked well together to provide safe care that met people’s individual needs.For example, theprovidermaintainedsafestaffing levels.Staff were well trained, felt supported and valued, and knew the people they supported well. Staff feedback was positive, with one staff member telling us, “I feel listened to and able to contribute to service improvement.” Regular supervision supported staff wellbeing and development, contributing to good morale, confidence in roles, and consistent,high‑qualitycare.

The provider did not always assess or manage the risk of infection or consistently detect and control the risk of it spreading.For examples,cereals had been decanted into containers without consistent staffoversight,and some food items were past their expiry dates.We found concernsregardingthe storage of cleaning equipment. Mops and mop buckets were stored in a communal bathroom.These issues were raised with theregisteredmanager.

However,personal protective equipment (PPE) was readily available, staff had receivedappropriate training, and the home wasobservedto be mostly clean and tidy. In addition, colour-coded chopping boards were in use to reduce the risk of cross-contamination.

On the second day of the inspection, improvements had been made. Decanted food containers had been removed and replaced with original packaging. People told us they preferred this approach as it allowed them to clearly see the contents. Theregisteredmanager hadtaken action to addressthe storage of cleaning equipment, and we were informed an outdoor storage shed had been ordered to ensureappropriateand hygienic storage going forward.

The provider did not always make sure medicines and treatments were safe. For example, medicines were stored in a locked cabinet; however,we found the medicines cabinet was unclean and a dirty spoon with medicine residue was present, despite disposable medicine pots being available. Homely remedies were stored communally rather than beingperson‑specific, and some medicine labels were worn or unclear. Handwritten instruction stickers were attached without evidence these had been checked or verified. Although monthly medication audits were in place, these had notidentifiedthe issues found during our visit. These concerns were shared with theregisteredmanager.

On the second day of the site visit, we sawappropriate actionshad been taken to address these concerns. The medicines cabinet had been cleaned, homely remedies had been reviewed to ensure they wereappropriate, and medicine labelling had been clarified. The registeredmanagerconfirmed oversight had been strengthened to prevent a recurrence of these issues.

Despite the concernsidentified, people received their medicines as prescribed and at the correct times. Staff had received medicines training, with competencies checked annually, and had access toup‑to‑datemedicines policies,proceduresand good practice guidance.