Kairos Community Trust

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

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.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

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

The service had no serious incidents in the last 12 months.

Staff knew what incidents to report and how to report them. Staff reported all incidents that they should report. The service had a low number of incidents. We reviewed three incidents, follow up actions taken by the service were documented.

Leaders told us that learning was shared with staff through team meetings and daily handover meetings.

The service 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’s referral and admission processes ensured that staff received all essential information needed to determine whether they could safely meet a client’s needs. The service had clear exclusion criteria and did not accept applications from people who were unable to manage their medication, those who found it difficult to manage their behaviour, people whose physical health needs meant they could not leave the building safely in an emergency, or people whose mental illness would make it difficult for them to engage in the therapeutic programme. Clients would only be admitted to the service following a successful detoxification process with 8 days of abstinence being required prior to admission.

Staff involved all the necessary healthcare and social care services to ensure clients had continuity of safe care, both within the service and post-discharge.

There were a variety of ways in which people could be referred into the service, including self-referral or referral by other agencies.

Discharge policies outlined a clear process for planned and unplanned discharges from the service. This included liaison with referring agencies, family and the person’s GP where appropriate.

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

All clients we spoke with told us they felt very safe and well looked after at the service.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. Safeguarding procedures were followed when children were visiting the service.

Staff we spoke with told us they knew who to raise and report safeguarding concerns to. Safeguarding adults and children training was mandatory, and compliance at the time of the inspection was over 85%.

Both commissioners reported that staff responded appropriately to safeguarding concerns. For example, staff supported one client who was a victim of domestic violence to move to another service after their location was identified by the perpetrator.

In the previous 12 months the service had made no safeguarding referrals to the local authority.

The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to clients and themselves well. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

All clients we spoke with told us that they were involved in their care and risk management. They reported that staff communicated clearly with them so that they understood their care and treatment. Clients confirmed they had a copy of their care plan and were aware of the expectations regarding abstinence and the procedures in place to support a safe environment.

We reviewed 8 client records, all of which contained an up-to-date risk assessment and management plans.

Staff told us if they were concerned about a client’s physical health, they would refer to the GP or call emergency services. Staff ensured clients had good access to physical healthcare. Staff ensured that clients were registered with a local GP who was well-known to the service. The GP carried out diagnostic checks, such as screening for blood-borne viruses. The GP made referrals for further tests and treatment at the local hospital when appropriate.

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Staff completed a risk assessment of the care environment every three months. Ligature cutters were available on site, but they were not easy to locate, and there was no signage to indicate where they were kept. There was no system to check items in the first aid box.

External contractors carried out maintenance checks on gas, legionella, portable appliances and fire equipment.

Fire safety arrangements were in place. The service completed weekly fire alarm tests and carried out regular fire drills with clients. However, the building’s fire risk assessment had not been reviewed since 2020. After the inspection, the provider told us they had taken steps to address this.

Clients told us they felt safe at the service. The service complied with guidance on eliminating mixed-sex accommodation. Of the 14 clients at the service at the time of the inspection there were 2 women and 12 men. The service allocated bedrooms to women in a specific area of the building. A toilet and bathroom were designated for the use of female clients only. Female clients told us they felt safe.

Staff carried out random checks of clients’ bedrooms to ensure they were maintained to a reasonable standard of tidiness and that medicines were being stored safely.

The service made sure there were enough qualified, skilled and experienced staff on duty. They worked together well to provide safe care that met people’s individual needs. Staff received effective support; however, we found gaps in record keeping in relation to supervision, training and staff recruitment.

Clients told us there were enough staff available and knew how to call for support out of hours.

The service had a small staff team. This included the registered manager, deputy manager, one counsellor, one trainee counsellor, one chef and one support worker. These staff worked at the service during the day from Monday to Friday. The support worker worked from 5pm to 8am, sleeping on the premises. A volunteer support worker provided nighttime cover at the premises during weekends. There were no staff or volunteers at the premises during the day at the weekends. Clients and support workers could contact the manager or deputy manager outside office hours, in accordance with an on-call rota. The on-call telephone number was displayed by the house telephone and at the entrance to the premises. Clients we spoke with confirmed they knew who to contact out of hours and how to do this. The manager ensured that annual leave was booked in advance to ensure sufficient staff cover. Sickness cover was usually covered within the staff team. If this was not possible the provider could temporarily move staff from other services run by the organisation.

The service had two vacancies at the time of our inspection.

Staffing levels allowed clients to have regular one-to-one time with their named staff member. This was confirmed by the clients we spoke with.

Staff told us they had completed their mandatory training, and the training offered was appropriate for the people using the service.

However, not all staff were up to date with their mandatory training. Training information provided by the provider showed that no infection control training had been undertaken since 2020.The training information did not detail the action taken when staff could not attend booked training such as health and safety training. These gaps meant the provider could not be assured that staff maintained the up-to-date knowledge required to carry out their roles safely.

The provider had booked for all staff to undertake mandatory training in learning disability and autism.

Staff told us they received regular supervision and felt supported in their roles. Counselling staff also received external supervision. However, when we reviewed three staff files, we found that supervision records were not up to date and contained several gaps. The lack of clear and consistent documentation made it difficult to determine whether staff were receiving the required supervision. As a result, we could not be assured that staff were being provided with regular opportunities to reflect on their performance, identify development needs, or receive feedback to support their ongoing professional development.

Recruitment systems were in place to ensure staff were suitable to work with vulnerable adults. However, for 1 staff member there was no risk assessment in relation to a Disclosure and Barring (DBS) check. The manager reported that this information would be held at the head office.

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

Clients told us the environment and therapy rooms were clean and appropriate to their needs.

All areas were visibly clean, had good furnishings and were well-maintained.

Cleaning activities formed part of the therapeutic programme for clients, who were responsible for cleaning their bedrooms, the kitchen, and communal areas in line with a daily cleaning rota. Cleaning checklists were displayed in the kitchen and toilet areas. The service also employed a cleaner who attended once a week.

The local authority had awarded the service a food hygiene rating of five out of five.

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

Clients told us they were supported by staff to manage their medicine needs. Staff followed good practice in medicines management. No medicines were prescribed at the service; all medicines stored on-site had been prescribed externally. Clients’ medicines were reviewed during the pre‑admission assessment, and any ongoing prescribing was continued through a local GP. As part of the pre‑admission process, clients were assessed for their ability to self‑administer their medicines.

Staff followed systems and processes to ensure medicines were administered safely. Medicines were stored securely. Each client had a secure locker. Clients were supported by staff to access their prescribed medicines. Staff maintained a medicine log and carried out regular medicine audits.

The service had a controlled drugs policy and a controlled drugs register and this was up to date. Prescriptions for medicines were issued by the clients individual GP, who also monitored their physical health needs.