Kingston House

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 remained 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.

The provider was in breach of legal regulation in relation to recruitment and safe premises and equipment.

This service scored 62 (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.

All accidents, incidents and medicines errors were documented and fully investigated by the registered manager to identify areas of possible learning or improvement. Where learning was identified, this information was shared effectively with staff to minimise the risk of similar events reoccurring.

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.

The service worked with partners to ensure any transfers of care were as smooth as possible and that people’s needs were recognised and understood. Information about people’s specific needs and preferences was available to be shared with healthcare colleagues in the event of a hospital admission and staff were able to provide support for people while they were in hospital.

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.

Relatives were confident people were safe at Kingston House and told us, “I am happy, [My relative] is safe there”.

Staff understood their role in protecting people from abuse and discrimination. They were confident the registered manager would act on any safety concerns they raised and knew how to make safeguarding alerts.

The service had systems to support people with the management of their money and ensure they were protected from the risk of financial abuse.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA, whether appropriate legal authorisations were in place when needed to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met.

Assessments of people’s capacity to make decisions had been completed. Where people lacked capacity, and their care plans were restrictive, necessary DoLS applications had been made. Where restriction had been authorised with conditions, these conditions were understood and complied with.

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.

Risks in relation to people’s care and support needs had been assessed and effectively mitigated. Staff had the skills necessary to safely support people’s mobility needs and used equipment appropriately when required. Risks to people’s skin integrity had also been mitigated and people were supported to change position regularly.

Staff knew people well and were able to recognise when people were becoming anxious or upset. Care plans included guidance for staff on how to help people manage their anxiety, including specific techniques and approaches that had previously been used successfully. Staff said they did not restrain people and told us, “There is no restraint, we keep [person name] safe” and “They are safe here. Nobody is aggressive, they are fine”.

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

Risks in the environment of the service had not been recognised or effectively mitigated.

There were uncovered radiators in both people’s rooms and an unrestricted window on the first floor which one person could access independently. No assessments of these risks had been completed by the provider which meant people were unnecessarily exposed to risk of harm.

In addition, in 2023, 3 ‘Potentially Dangerous’ faults had been identified during an assessment of the service’s electrical circuit. The registered manager did not know if these faults had been addressed and there were no records available to demonstrate these faults had been resolved by suitably skilled contractors. The provider’s failure to address these faults meant people and their support staff had been unnecessarily exposed to risk of harm for a significant period.

The provider’s failure to ensure the service was safe and suitable for people’s needs was a breach of the requirements of regulation 15 Premises and Equipment of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Necessary checks on firefighting and lifting equipment had been completed and checks and tests had been completed on the service’s water supply. Personal emergency evacuation plans were available detailing the support each person would need in the event of an evacuation.

The provider did not have safe systems for the recruitment of new staff. However, there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to meet people’s individual needs.

The service’s recruitment practices remained safe. Although Disclosure and Barring Service checks had been completed, the service had failed to confirm the identity of new staff before they began working in the service. In addition, risks in relation to recruitment decisions had not been documented when referees failed to provide feedback of a prospective staff member’s previous performance in care or where staff had begun working before the outcome of DBS checks were received.

However, there were enough staff with the skills necessary to meet people’s needs. The registered manager told us, “Sometimes we are overstaffed, staff have contracts, but we have not reduced hours”. On the first day of the assessment the service was initially understaffed as a staff member had slept in. Rotas showed planned staffing levels were normally achieved and staff said, “Staffing is normally ok - some sickness and can have bank when needed” and “It’s unusual for staff to be short. It does not normally happen”.

Staff training was regularly updated and staff received regular supervision. Staff told us, “We do online learning” and “The training is online, it is ok”.

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.

The service was clean and staff understood how to manage infection control risks. Staff had access to appropriate Personal Protective Equipment (PPE) which was used appropriately when required.People’s care plans included specific guidance on the management of infection control risks associated with their individual needs and activities.

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.

Systems for supporting people with their medicines had improved and people now received their medicines as prescribed. Medicines were stored safely and Medicines Administration Records had been accurately completed. Staff had appropriate guidance on how to support people with their medicines. Medicines records were reviewed and audited by the registered manager and the service had engaged with prescribers for advice where people’s routines impacted on the timing of their medications.