Kingsley

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 registered manager and staff had a proactive and positive culture of safety, based on openness and honesty. Accidents and incidents were rare because staff knew people well and understood what may place them at risk. Staff knew what may cause people to become frustrated or upset and worked with people to avoid any triggers. People were supported to take risks where they wished and action was taken to mitigate risks to them.

The registered manager 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. No one had moved into the service for several years. However, the registered manager had a process in place to meet people and understand their health and support needs before they were offered a service. They considered people’s personalities and made sure people would get along before they offered people a service.

The registered manager and 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 staff and registered manager knew how to share concerns quickly and appropriately. Action had been taken to protect people from the risk of harm when concerns had been raised. These had been shared with the local authority safeguarding team for their consideration.

People can only be deprived of their liberty to receive care and treatment with 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 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. People had capacity and did not require DoLS authorisations. Where people had other restrictions on them, the registered manager worked with other professionals to make sure people were supported to have as much freedom as possible.

The provider had not always ensured staff were aware of how to provide safe care to meet people’s needs. Staff were unaware of the actions to take if some people had an epileptic seizure. Guidance was in place about how to keep the people safe however, staff were not aware of it. No one had had a seizure for many years however; however it is important staff know to recognise a seizure and the action to take to keep people safe if they have a seizure.

Other risks to people had been assessed and staff knew how to keep them safe. For example, the risks of people falling had been assessed and staff had worked with health care professionals to get the equipment people needed to mitigate risks, such as walking aids. Staff knew who was at risk of choking and ensured their meals were prepared to keep them as safe as possible.

Staff understood what caused people to become anxious, or frustrated, such as noisy environments or feeling left out. They explained these to us and supported us to interact with people in a way that was best for the person.

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

People showed us around the building and grounds. We observed wooden handrails at the front of the building, which people used to help them walk to and from the front door were very rough and there was a risk of people getting splinters from them. Wooden garden furniture also had a very rough surface and placed people at risk of splinters. There were no covered areas in the rear garden. The sun was warm on the day of our visit and we observed people choosing to sit outside had no shaded areas to sit and were at risk of sunburn. The provider sent us an action plan to address these shortfalls after our site visit.

People and staff had practiced how to remain safe in an emergency, including fire drills. Risk assessments were in place regarding how best to protect people who refused to leave the service during some drills.

The provider did not always make sure staff received effective development. Staff had completed eLearning but had not been supported to complete practical training in key areas such as moving and handling and first aid. Some staff’s competence to complete practical tasks had not been assessed to ensure their practice was safe. This left people at risk of not being supported safely.Staff had completed face to face Oliver McGowan training on Learning Disability and Autism, this is the Government’s preferred and recommended training for social care staff.

There were always enough staff on duty to provide the support people wanted. We observed staff support people to do what they wanted each day. This included going out and about, doing household tasks, such as shopping and cleaning and taking part in pastimes they enjoyed. Staff shifts were flexible to people’s needs, for example, if people wanted to stay out late in the evening, staff were deployed to support them.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading. The provider had an infection control policy in place but this did not reflect national guidance including Department of Health and Social Care Infection prevention and control: resource for adult social care. Detailed guidance had not been provided to staff about the action to take in the case of an outbreak at the service and how to protect people from infection risks.

We observed some furniture, in communal areas, was not easy to clean and the fabric of some seating was torn and could not be easily wiped. Some wooden furniture was no longer sealed and had a rough surface making it hard to clean. The provider sent us an action plan to address these shortfalls after our site visit.

People told us they cleaned their bedrooms and communal areas with staff support. Personal protective equipment such as disposable gloves were available for staff supporting people with personal care.

The provider did not always make sure that medicines were safe and met people’s needs.

Detailed guidance had not been provided to staff about when they should offer people ‘when required’ medicines. Including the signs the person needed the medication and the maximum amount to be administered in a 24 hour period. Administration records showed ‘when required’ laxatives had been administered when people needed them and had been effective, however, there was a risk people who could not tell staff they needed the medicine, would not consistently receive their medicines when they needed them and in a safe way.

National guidance had not been followed when managing medicines away from the service. A risk assessment had not been completed to demonstrate why medicines had been removed from their original packaging when people went to staff with relatives and the processes put in place to ensure they were administered safely. There was a risk people would not get their medicines as prescribed.

The temperature medicines were stored at was not checked to ensure they were always held at the temperature recommended by the manufacturer. Becoming too hot or too cold can impact on the effectiveness of medicines, meaning people may not receive the maximum benefit from them.

Effective processes were in place to order and dispose of medicines. Medicines were stored securely. Medicines administered were recorded correctly.