Kenilworth Manor

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 inspection we rated this key question good. At this inspection the rating has

remained good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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.

Regular meetings with people who lived in the home, and their relatives, ensured they had opportunities to raise any concerns. In addition, there was a committee made up of 2 people who lived in the home, a relative, the registered manager and key staff. The committee represented the views of those who lived in the home and met regularly to discuss service delivery and areas where improvements could be made. We saw evidence of improvements being made in response to the committee’s feedback. One person told us, “I am a resident committee member; we have meetings, and any issues are dealt with and there are not much at all.”

Staff told us they were encouraged to report any safety concerns so action could be taken to prevent further occurrences. One staff member told us, “We get told in handover what has happened so we can reflect on it and see what we can do to stop it happening again. If there is anything that needed to be said immediately, there would be a meeting there and then."

Complaints were investigated and responded to. We found concerns were acted on in a timely way and resolved to reduce reoccurrence.

The provider shared learning across the organisation, and when an incident happened at 1 of the provider’s services, information was shared with all managers through online meetings. The registered manager then cascaded this to the staff team through daily handovers or team debriefs.

The provider 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.

People told us they were given time and information to make decisions prior to moving to the home. People were mostly met, and their needs were assessed by the registered manager or deputy manager prior to admission. However, when referrals needed to happen quickly, for example from a hospital setting, the registered manager worked in conjunction with trusted staff in the hospital to obtain necessary information that ensured staff at Kenilworth Manor knew how to provide good care.

When people needed to attend medical appointments, they were supported to organise these by staff in the home. Where relatives were unable to accompany their family member, staff accompanied people so information could be shared, safely and effectively, with other health and social care professionals.

Staff knew what information needed to be shared in urgent situations, and the care planning system ensured all necessary information was promptly available to other health care providers taking over emergency 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, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People living in the home felt safe. One person told us, “I feel very safe living here.” Another said, “I feel safe here, there are always people around me, it’s like one big happy family.”

Staff understood their responsibility to report concerns if people were at risk of harm or discrimination. One staff member told us, “I have no qualms about whistleblowing. It is not just physical abuse but tone of voice and the way others speak that would bother me." Another staff member told us they would not hesitate to report poor practice by a colleague that put people at risk. This staff member commented, “If it is not safe, it is not right. We have to look after the residents and at the end of the day it is our privilege to care for them, and it is our responsibility." A third staff member told us they would follow the whistleblowing policy to escalate concerns if they felt action had not been taken to safeguard people.

Safeguarding referrals were submitted in a timely manner and there was information available which informed staff how to raise safeguarding concerns.

When receiving care and treatment, people can only be deprived of their liberty with the appropriate legal authority. In care homes, this can be done through a procedure called The Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act (MCA) 2005. We checked how the provider managed DoLS within the home. Where people had restrictions placed on their liberty, this was reflected in their care plan. For example, where a person had been assessed as lacking capacity to consent to care, the provider had ensured DoLS applications had been submitted to the relevant supervisory body.

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.

People had assessments in place which identified risks and provided guidance to staff on how to provide care in a safe way. Where people were living with more complex needs, we found assessments were thorough, informative and written in an accessible way which meant all staff could be clear on how to safely support people.

One staff member described a collaborative approach to managing risks around people’s mobility. They explained, “I won’t make a decision (about risk management strategies) without the support of the nurses, the care team and the resident. A lot of residents have capacity, so it is really important to get them involved so they can explain what they find comfortable and meets their needs. Good manual handling is minimal handling and encouraging their independence."

Staff told us the electronic care planning system provided guidance as to the care interventions required to mitigate identified risks to people’s health and wellbeing.

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

The provider ensured relevant safety checks were completed as required in relation to gas, electricity, water, Legionella, and equipment safety. A monthly audit by the registered manager ensured these checks had been completed and any concerns had been rectified. Staff completed checks to ensure equipment such as call bells, air mattress settings and bed rails were safe for people’s use. One staff member explained, “There is a label on the hoist with the last inspection date and before using the hoist we have to check it is working properly and that the battery is fully charged.” We saw systems in place for staff to report any faults or concerns with the environment.

Staff received training on fire safety, and we reviewed evidence of fire drills taking place to ensure their training was effective. On the day of our inspection, a routine fire bell test identified a concern with 1 fire door. This was noted by the maintenance person in the home and escalated to the provider’s maintenance team who took immediate action to ensure it was safe.

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.

People and relatives were satisfied with the availability of staff and the support they provided. One person told us, “I think that the staff know what they are doing and are properly trained to meet my needs.”

Our observations confirmed staffing levels were well maintained, and agency staff were used when necessary. Staff considered there were enough staff to safely provide the care outlined in people’s care plans but acknowledged some days were busier than others. Comments included: “We have enough staff right now. If we have a problem, we go to the manager and say we need 1 more staff and she listens," and “I think you could have more, but it works well here. It is a nice team, a strong team and everyone works well together."

Staff were visible and available to people. The registered manager explained how she reviewed staffing in the home, and when necessary, had autonomy to increase staffing levels. This was supported by the provider.

Staff had been recruited safely in line with the provider’s policy and best practice guidance. However, we received feedback that some aspects of the induction process could be more robust, so it was more reflective of the previous experience of new staff in health and social care. Staff had completed appropriate training through a mixture of online and face to face sessions, and some staff had received additional accreditations such as NVQs, Mental Health First Aider and a qualification to support and monitor staff with safe manual handling.

The provider operated an on-call system which ensured staff always had access to advice and support.

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.

People and their relatives told us the home was clean, and they had no concerns. We saw bedrooms and communal areas of the home were clean and tidy. Personal protective equipment was available, and staff were seen using and disposing of it appropriately. Staff were trained in infection prevention and control and were able to describe what processes were in place to keep people safe. Clinical rooms were clean and well maintained.

People who were at greater risk from infection had detailed care plans which told staff what practices they needed to follow to reduce the risks.

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

People told us they received their medicines regularly and by staff who were trained to administer them. One relative told us that they had seen staff obtain consent and respect people’s choices around their right to refuse medicines.

Medication was stored securely and safely and the home ensured they had an adequate supply of people’s medicines. The home used an electronic system which evidenced accurate administration, and easy to follow information about when people needed their medicines. People’s individual care plans included information about their medicines and any side effects they may cause. Where people were prescribed as required medicines, for example laxatives, pain relief or medication to ease anxiety, these were given when people needed them. Staff had guidance to ensure these medicines were given consistently and safely.

Records evidenced that all staff who administered medicines were trained to do so and their competency to understand safe processes was checked regularly.