Kingston House

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• 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

We reviewed all of the quality statements in this key question.

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.

Systems were not robust to make sure all possible risk mitigation was identified and discussed following incidents to prevent reoccurrence. We found 1 incident which had been reviewed by management where a person had left the building at night. Whilst the person was unharmed no consideration had been given to placing alarms on all ground floor external doors. The provider organised for alarms to be fitted to external doors during our site visit. Falls and incidents had been reviewed and analysed but it was not recorded that all factors had been considered. For example, times of falls had not been analysed to identify any trends.

Staff completed incident forms following any accidents or incidents. Management told us they reviewed all incidents to make sure the required actions had been completed. Any learning points were discussed in handovers or staff meetings to share actions to prevent reoccurrence.

Relatives told us staff always called them when things went wrong, and they could see action taken to help prevent further incidents. Comments from relatives included, “They [staff] are pretty good at calling me if necessary. [Relative] has not had any falls for ages; [relative] has a sensor mat” and “In recent times [relative] has been falling out of bed and they [staff] have put a crash mat by the bed and lowered it.”

Staff told us a pre-admission assessment was carried out. This was usually done face to face but if people lived outside of the local area, it could be completed on the telephone. Within a month of people moving in, staff reviewed their care plan to make sure it was accurate.

People told us staff had got to know them and knew their needs, which could be shared with healthcare professionals if needed. Comments from people included, “Staff have got to know me, what I like and don’t enjoy” and “They [staff] know me well and what I like.” One relative told us when their relative had gone into hospital this had gone well. They said, “Staff had to get the doctor in, [relative] had a chest infection and had to go to hospital, it all went very smoothly.”

One healthcare professional told us they had a good relationship with staff at the service. They told us if they needed any assistance, they could ask the staff and work together to make sure people’s needs were met.

People had transition documents in their care plans to be used when people went into hospital. These records gave healthcare professionals information about people’s needs and any medicines being prescribed. People were assessed prior to moving into the home. This assessment was used to help staff produce an individualised care plan.

The provider had a safeguarding policy which provided guidelines for staff to manage any safeguarding alerts. Safeguarding concerns were recorded and shared with the local authority. Staff had applied for Deprivation of Liberty Safeguards (DoLS) and some people had been assessed by the local authority. Where DoLS had conditions attached to the authorisation, the provider was meeting them.

People and relatives, we spoke with told us they felt safe at the service, and they were happy living at Kingston House. One relative told us, “[Relative] feels safe and would tell me if that changed.” One person said, “I am well looked after and if you want anything they [staff] will get it.”

We observed at times people were not always safe as there were not enough staff to provide support in a timely way. On 1 occasion we had to step in and seek staff assistance from management to help support people in distress. We observed the whistleblowing policy was on the notice board in the staff rest area. During a daily handover meeting we observed senior staff checking with others if there were any safeguarding concerns to report.

Staff told us they knew how to report any safeguarding concerns and knew where the safeguarding policies were stored. They had received training on safeguarding and had the opportunity to raise concerns at staff meetings and handovers. One member of staff told us, “If I needed to report anything in the home, I would go to management. If it was management I needed to report, I would go higher.”

Staff were not clear about the support needed for 1 person who experienced distress. Staff told us the guidance was confusing which meant they were unsure on how to provide care. Management told us they had monthly meetings with senior staff to discuss risk so that risk assessments could be updated.

People told us they were supported by staff safely. Comments from people included, “I use a walker to help me get along, staff support me well” and “Staff are always very careful and treat me respectfully.” One relative said, “Staff are very good and making sure [relative] is relaxed before being moved. They talk to [relative] while they are moving them to keep them at ease.”

There were times when there was not enough staff and we observed they were not able to respond to people’s distress safely. We observed staff using equipment safely when supporting people to mobilise.

People had risk management plans in place for a variety of identified risks. However, we found they did not contain enough details for staff to know what care was needed. We also found some risk assessments had been completed incorrectly which gave people a lower score of risk than was accurate. For example, people with behaviour support plans did not have clear guidance on what staff were to do if people became distressed. People with poor skin integrity did not have their risk management plans completed by staff correctly. This meant they did not have correct scores which indicated they were a lower risk of developing pressure ulcers than was accurate. Where people had been identified at risk of malnutrition or dehydration food and fluid charts were in place. We found these had not been completed by staff in any details to help monitor the person’s food and fluid intake. People who experienced distress did not have enough guidance in place for staff to know how to provide person-centred support. Internal governance systems had failed to address these shortfalls. Failing to have effective systems in place to assess, monitor and mitigate risks was a breach of Regulation 17 (good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People were pleased with their own rooms and had the equipment they needed to mobilise safely.

Service records demonstrated safety checks were being completed for areas such as fire systems, legionella and gas safety. Equipment was being checked regularly to make sure it was safe to use.

On the first day of our site visit we noted the environment had some hazards with the potential to cause harm. For example, a display cupboard was in a corridor with a glass pane on the floor next to it, a foot stool was being stored on top of the cupboard which was a hazard. A cupboard was so full of equipment the door could not be closed and bathrooms were being used to store items such as blankets and a lamp. We raised our concerns with the provider following this initial visit and they did take action to make the environment safe. However, we observed the bathrooms continued to be used for storage of items such as mattresses. Management told us they would address this practice.

Management told us they did a daily walk around to monitor the environment for safety concerns. There was a system in place for staff to report any concerns with the environment so they could be addressed.

The provider used a dependency tool to calculate staffing numbers which was based on people’s needs and reviewed monthly. However, for 1 person who was needing at times a 1-1 staffing ratio we found they were assessed as ‘low’ dependency which would indicate minimal staffing assistance. We also found another person was assessed as being independent with their continence management when staff were having to support them with this. We were not assured the dependency tool was accurate in making sure the right numbers of staff were available. The provider had a recruitment policy and staff had been recruited safely. Staff were provided with an induction when they started work and regular refresher training.

Staff told us there were times where there were not enough staff available. Staff told us staffing levels were not always sufficient for them to respond to people’s needs in a timely way. Staff also told us they did not feel there were enough senior staff available as some days only 1 senior was on duty for the whole service. Staff said when this happened they had to wait at times to get the assistance they needed from senior staff. Staff told us they felt supported in their roles and had opportunity to attend meetings and supervisions. Staff also told us they felt their training was good and helped prepare them for their work effectively.

There were mixed comments from people and relatives about staffing numbers. Overall people told us they thought there were enough staff available to meet their needs. However, some relatives told us they did not think there were always enough staff available. People told us staff employed by the provider were well trained, however, they were less confident about agency staff. Some relatives also told us they had concerns about agency staff being trained and competent.

We observed there were times when there did not appear to be staff available to respond to people’s needs. We observed people experiencing distress, but we could not find staff to respond so we sought assistance from management. They came to help but staff told us the situation was a regular occurrence as there were not enough staff on duty at all times.

Staff were not clear who was responsible for some cleaning duties. Management told us they walked around the home on a daily basis and addressed any cleanliness concerns if seen. They also told us some infection prevention and control shortfalls were due to people's behaviour but they were not able to tell us the management approach to the concerns.

On the first day of our assessment, we found some communal areas were dirty in places and areas were cluttered which would prevent thorough cleaning. For example, we observed cobwebs in kitchenette areas and walls that were dirty with food debris. We shared our findings with the provider who took action to address the shortfalls. We also observed some staff practice which did not follow good infection prevention and control guidelines. For example, some care staff were seen to be wearing rings with stones which carry risks of cross contamination.

People and relatives told us they found people's rooms to be clean. People also told us they saw staff wearing personal protective equipment when needed.

Infection prevention and control audits completed were not effective in identifying areas of concern. Audits completed for the 4 months prior to our site visit recorded a 100% compliance with all areas. This was not accurate as we identified areas that required an immediate clean. The audit also did not identify areas of the home which needed a review of flooring and furniture due to concerns about cleanliness. Cleaning schedules recorded staff had cleaned communal areas such as dining rooms and kitchenettes. However, we found these areas had not been cleaned thoroughly. The provider had put up signs on doors of the main kitchen informing staff to wear blue aprons when entering the kitchen. We observed staff were not following this notice. Failing to have effective systems in place to assess, monitor and mitigate risks relating to the health and safety of people and staff placed them at risk of harm. This was a breach of breach of Regulation 17 (good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Staff told us the morning medicines round could be difficult if there was only 1 senior member of staff available to administer medicines. Some days staff told us the morning round could take 3 and a half hours which had an impact on when lunch time medicine could be administered.

People were happy with the support they had with their medicines. Comments from people included, “Staff are very good with my tablets, never miss and always gets here on time”, “I can get painkillers, if I need them the one who does the tablets brings them in” and “I have no worries about my medication, it is all discussed with me.”

The provider used an electronic system for managing medicines which helped staff make sure people had their medicines as prescribed. Staff received training on medicines administration and had their competence checked. Medicines were being stored safely and staff carried out regular stock checks.