Kensington Hall

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 requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 72 (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. Relatives and staff told us they felt people were kept safe and any concerns in the home were listened to and acted on. A relative said, “If I am not happy with something, I just mention it and it is sorted.” A staff member told us, “All incidents and accidents are recorded and passed over in the daily handovers.” The registered manager conducted reviews of safety incidents to look at areas of learning and shared these with staff.

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. For example, one person’s initial assessment had been completed at another service they attended. Assessment documents from this other service were available for staff, so they had a comprehensive picture of the person’s support. Professionals told us staff gave them appropriate and timely information to support safe care.

The provider did not consistently work 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 in most cases. However, in some cases, incidents had been shared with the local authority safeguarding team but not shared with CQC as legally required. In other case staff had reported incidents to safeguarding that had a known cause and that did not need to be reported. Although there were reporting shortfalls, in all instances the provider had taken actions to make the person as safe as possible and reduce risks.

Staff had up to date safeguarding training and knew how to recognise and respond to signs of abuse. A staff member told us, “If I suspected abuse I would report it to the manager immediately.” A relative told us, “My loved one is always happy and relaxed and if there were any concerns they would show it, and I would know.”

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. We found that staff recognised when people needed DoLS and made appropriate referrals. Where DoLS were in place staff knew what this meant for people and followed the conditions imposed.

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. Staff told us how they involved people in their own care and support and enabled them to take informed risks. Risk assessments were in place explaining how risks could be reduced and managed, these were regularly reviewed.

Staff knew people well, which helped them understand risks and help people to manage these. A staff member told us, “Yes, I feel like people are safe. To keep people safe, I have engaged with ongoing training, recently went to in person training, read policies and procedures and care plans to familiarise myself with people and their needs.” A relative told us, “I have full confidence in the staff team to keep my loved one safe, they know my loved one well and they show that they have received good training."

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 well maintained and there were processes in place to check on equipment and facilities. Equipment was appropriately serviced. There was a clear process for any maintenance needed in the home and issues were addressed promptly. For example, when we visited the home, a toilet had broken and was being repaired the same day. There was an ongoing program of redecoration and repair in the home.

The provider completed regular fire safety checks. Staff helped people to understand what to do in the event of a fire. One person in the home had their own fire file and had been asked to complete a register when there was a fire evacuation practice. This had encouraged the person to take part in evacuations and have a better understanding fire safety.

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. Recruitment practices were meeting requirements. We observed staff spending time with people and support was unhurried. There were enough staff to support people to do things for themselves where possible. A relative told us, “Whoever is working when I visit has time to chat to me. I will often arrive and see a member of staff chatting to my loved one. I never get the feeling staff are rushed”.

Staff told us they felt supported in their roles, including having regular supervision and training. Staff were trained in a variety of subjects relevant to the needs of the people they supported. A relative said, “Staff have been going on a lot of training, for example, all staff have attended a positive behaviour course”. The provider was meeting the Oliver McGowan code of practice in relation to training. Oliver McGowan training is in relation to learning disability and autism and is a statutory requirement.

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. Overall, the home was clean and well maintained. A shower, that was not currently in use, required additional cleaning and some radiators had areas of rust. We raised these issues with the registered manager, and they were addressed straight away.

People were supported to keep their home clean and tidy, and staff also regularly cleaned. Staff and management completed frequent checks of the environment and equipment. The home had recently had a visit from the local NHS infection prevention and control team and there were no required actions from this.

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 practices had improved since the previous inspection. Records and guidance for topical (such as creams applied to the skin) and when required medicines were in place and up to date. Medicines were administered as prescribed and staff had appropriate training. Staff ensured medicines were reviewed if people’s needs changed, and in line with ‘Stopping over medication of people with a learning disability and autistic people (STOMP)’. A relative told us, “The team look after all my loved one’s medical needs. They arrange appointments, look after medication and make sure they are taken on time.”