Kirkstall Lodge

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: Key question summary

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 as good. At this assessment the rating has remained as good. This meant people were safe and protected from avoidable harm.

This service scored 72 (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

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

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

The provider assessed people’s needs before admission and coordinated care with health and social care professionals, including GPs and community services. These arrangements supported continuity of care and helped people to move promptly from hospital to the service.

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.

Staff understood risks to people’s safety and how to support people to manage those risks. Care records contained information about risks to people’s safety and welfare, and staff worked with people to maintain their independence whilst keeping them safe.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Effective systems were in place to ensure the premises and equipment were safe, which included regular maintenance checks to meet health and safety regulations and fire safety arrangements were well organised, with regular checks and staff training and drills to ensure staff understood their roles in an emergency. Personal Emergency Evacuation Plans (PEEPs) were in place, accessible, reflected people’s individual needs and provided clear guidance for staff.

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 registered manager ensured there were adequate staff employed to meet people’s needs. Safe recruitment practices were in place to ensure suitable staff were employed. New staff completed a full induction process as well as completion of their mandatory training and competency checks to ensure they had the knowledge and skills to undertake their duties. Staff undertook regular refresher training to ensure their knowledge stayed up to date with best practice guidance.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

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. We found areas for further development in how medication information was recorded and documented. One person’s clozapine file did not yet include full, detailed guidance to support staff in managing their medication safely and in the absence of individual guidance could mean staff may not respond to missed doses or changes in the person’s health. However, the staff knew the person well, understood their medicines and worked closely and regularly with the local mental health clozapine team, maintaining good communication to support people on clozapine regimes, and we saw no concerns that the individual’s clozapine was being managed unsafely.

The provider confirmed this was not an isolated gap but a wider area for improvement across the organisation. A standardised clozapine template had been developed and shared with the service just prior to our visit, showing the provider had identified the risk and was taking action. The registered manager told us the provider had recently created a dedicated clozapine medicine template and was to put one in place immediately.

Protocols for medicines, including those prescribed as ‘as and when required’ (PRN), were not recently updated. We saw people’s medicine profiles had existed previously but had recently been removed; however, the registered manager recognised the profiles were needed to guide and support practice, and at the time of our visit these were in the process of being reintroduced.

People prescribed flammable topical emollients did not have risk assessments in place. We shared our feedback with the provider, who assured us they would complete these immediately.

Medicines were stored securely in people’s rooms with restrictions on access, and room temperatures were monitored regularly.

Staff had undertaken medicines training and competency assessments, which supported them to administer medicines safely.