Kynance Residential Home

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 changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 59 (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 demonstrate an effective learning culture. While systems were in place to record and review incidents, and there were examples of actions taken to address identified concerns, including changes to equipment and reminders issued to staff, this learning was not consistently embedded into day-to-day practice.

We found that lessons from previous incidents and areas of risk had not been fully translated into improvements in care delivery. For example, staff did not always follow professional guidance during mealtime support, and patterns of task-led care were not identified or addressed through existing monitoring processes.

This meant that opportunities to learn and improve practice were not always acted upon effectively, reducing assurance that risks to people’s safety, dignity and wellbeing were consistently identified and mitigated.

The provider worked with people and healthcare partners to establish and maintain safe systems of care and support people’s transitions into and between services. There was evidence that people’s needs were assessed prior to admission, and the provider was clear about the level of need they were able to meet safely. Staff described how they worked with external professionals to support safe admissions to the care home and ongoing care, and relatives reported being kept informed when people’s needs changed.

The management team told us they would provide appropriate information about peoples care and medicines should people require transfer to alternative care providers or for hospital admission. They explained that a staff member would support people if there were no family members able to do this. This demonstrated that systems and processes were in place to support continuity of care and safe transitions for people.

Safeguarding practice was not consistently embedded into day-to-day care. We identified examples where risks to people’s safety, dignity and wellbeing were not always recognised or responded to appropriately at the time care was delivered, particularly where care was delivered in a routine or task-led way.

This reduced assurance that safeguarding principles were consistently applied across the service. While staff demonstrated understanding of safeguarding processes and worked with external professionals appropriately, safeguarding was not consistently demonstrated in practice. For further information see the well-led section of this report.

The managers and staff described how they worked with external professionals, including GPs and district nurses. Relatives consistently told us they felt their family members were safe living at the service. Staff told us they had received safeguarding training and understood how to raise concerns, including escalating these internally and externally where required.

Systems were in place to support the appropriate application of Deprivation of Liberty Safeguards (DoLS), and the management team demonstrated an understanding of when referrals were required and the process to make these.

The provider did not always work effectively with people to understand and manage risks. Risks were not consistently managed in line with professional guidance.

People were assessed for risks such as skin damage, malnutrition, falls and choking. When risks wereidentified, care plans provided guidance for staff on how to reduce the risks.While care plans included guidance from external professionals, including Speech and Language Therapy (SaLT), observed practice did not consistently reflect this. During observations of mealtime support, we identified that a person was not supported in line with their SaLT guidance, including not being positioned appropriately and the use of equipment that did not reflect their assessed needs. This resulted in the person experiencing prolonged coughing and placed them at risk of harm. We raised this with the management team who took appropriate action, including reinforcing guidance with staff and increasing oversight of mealtime support. This demonstrated that while systems were in place to support evidence-based care, further work was required to ensure guidance was consistently embedded into day-to-day practice.

The provider 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. The environment was generally suitable for the people using the service and supported people to live safely and comfortably. However, the provider did not always ensure all risks relating to the environment were fully assessed and mitigated. We identified gaps in environmental risk assessments, which meant potential hazards may not always have been recognised or managed effectively. The provider told us they would review environment risk assessments to ensure these covered all relevant risks.

The provider ensured there were enough suitably skilled and experienced staff to meet people’s needs. Relatives and external professionals provided positive feedback about staff, describing them as kind, responsive and supportive, and people appeared comfortable in their presence. A relative said, “There are always staff around when I visit.”

Staff worked together and did not raise concerns about staffing levels. They told us they were generally had sufficient time to meet people’s needs.

Staff were safely recruited, and checks were carried out before they started work to reduce the risk of unsuitable staff being employed. Some records which providers are required to view as part of staff recruitment had not been maintained. The training was up to date and covered topics relevant to the service. A formal process was in place to support staff with staff meetings,regular1 to 1 and groupsupervisions,competencychecksand annual appraisals.A family member told us, “The staff seem well trained and caring.”

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 provider maintained a clean and appropriate environment that supported effective infection prevention and control. We observed the service to be clean and well maintained, and cleaning arrangements were effective in reducing the risk of infection. No concerns were identified during the inspection.

The provider’s systems were not always fully effective in ensuring all aspects of medicines management were consistently monitored and in line with best practice. People and relatives expressed confidence that medicines were administered correctly, reflecting generally safe practice. Staff demonstrated understanding of medicines procedures, including administration, storage and escalation. While the majority of medicines practices were safe, some minor areas for improvement were identified, including the recording of maximum and minimum storage temperatures and ensuring that opened medicines were consistently discarded when no longer safe to use. These issues were limited in scope, and prompt action was taken once identified, providing assurance that risks were recognised and addressed appropriately.