Kilfillan House Care 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 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.

Records showed lessons were learned and acted upon. For example, following falls incidents, risk assessments and care plans were reviewed to reduce the risk of recurrence while maintaining people's independence. Leaders also strengthened PRN (as required) medicine protocols following inspection feedback and acted on resident feedback regarding preferred routines and environmental improvements. Staff described an open culture where "concerns are taken seriously." This demonstrated a commitment to learning, openness and continually improving safe care.

The service demonstrated a strong commitment to learning, continuous improvement, and developing the quality of care provided.

Internal audits and action plans identified areas requiring further development, including International Dysphagia Diet Standardisation Initiative (IDDSI) compliance, care planning quality. Action plans evidenced monitoring, review and follow-up activity. (IDDSI) is a global framework that provides a common naming and testing system for modified food textures and thickened drinks for people with swallowing difficulties

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.

Information was shared appropriately to support safe and consistent care. Records contained detailed information about people's health conditions, risks, communication needs, dietary requirements, medicines and decision-making arrangements. We saw evidence of effective joint working with healthcare professionals, including General Practitioners (GPs), Speech and Language Therapists (SALT), community nursing teams and palliative care services. Advance care planning documentation, Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders and Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) forms supported continuity of care when people's needs changed or external services became involved.

Families and healthcare professionals were involved in decisions regarding treatment escalation, end of life care and future planning, helping ensure people's wishes were understood and respected across different services.

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.

Staff understood their safeguarding responsibilities and were confident in recognising and reporting concerns. Records showed risks were assessed and managed in a way which balanced people's safety with their rights and freedoms. For example, appropriate Deprivation of Liberty (DoLS) applications were in place to support a person who was unable to recognise risks to their own safety. Records showed staff responded appropriately following falls incidents, reviewing care plans, reassessing risks and implementing measures to reduce the likelihood of recurrence whilst continuing to support the person's independence and choice. This demonstrated staff considered people's safety, wellbeing and rights when planning care and support.

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 were involved in decisions about their care, daily routines and personal preferences. Care plans and risk assessments considered people's physical health, mental wellbeing, communication needs, independence, relationships and desired outcomes, helping ensure risks were managed in a person-centred way. Individual plans contained guidance relating to mobility, medicines, falls, nutrition, skin integrity and long-term conditions, while also recognising the importance of maintaining choice, dignity and quality of life.

Staff took a balanced approach to risk management, supporting people to remain as independent as possible whilst reducing the likelihood of avoidable harm. People reported being involved in decisions about their care and daily lives, demonstrating that risk management was tailored to the whole person rather than focused solely on safety

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 home was clean, welcoming and generally well maintained. However, we found several bedrooms and storage areas where clutter and poor organisation reduced the effective use of space and created avoidable environmental risks. Although people told us they felt safe and there was no evidence of actual harm, improvements were required to ensure the environment was consistently managed to support people's safety and wellbeing. The Registered Manager had acknowledged these findings and had started to take action to address the issues identified.

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 were supported by a dedicated and stable staff team who knew them well and understood their individual needs, preferences and routines. Staff told us, “We are fortunate to have a dedicated and stable workforce and do not routinely rely on agency staff." This continuity helped staff build positive relationships with people, recognise changes in their wellbeing and provide personalised care.

People and relatives consistently spoke positively about staff and described them as caring, knowledgeable and responsive. There were sufficient staff available to meet people's needs, and interactions were observed to be calm, supportive and unhurried. Recruitment, induction and training processes helped ensure staff had the skills, knowledge and experience needed to provide safe and effective care.

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 lived in a clean and hygienic environment where effective infection prevention and control measures were in place. We observed staff following good hygiene practices and using PPE appropriately when required.

The service had clear infection prevention and control systems supported by policies, staff training and regular auditing. Leaders maintained oversight through a programme of audits. Improvements identified through the audit had been promptly addressed through completed action plans.

Appropriate arrangements were in place for cleaning, waste management, outbreak management and the safe use of Personal Protective Equipment (PPE), helping to reduce the risk of infection and protect people's health and wellbeing.

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

Medicines were managed safely through an electronic medicines management (eMAR) system, with effective oversight of stock levels, allergies, refrigeration monitoring and controlled drugs. Staff had access to clear guidance to support safe medicines administration, and PRN protocols were strengthened following feedback during the assessment. A visiting healthcare professional told us they “Couldn't speak highly enough” of the service and the care people received. Staff worked closely with healthcare professionals when people’s needs changed to help ensure medicines remained safe, appropriate and effective.