Kingsmith Care

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

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 81 (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 strong, embedded learning culture where incidents, concerns, complaints, audits and feedback were consistently used to improve safety, practice and outcomes.

Leaders demonstrated a systematic approach to learning through the use of safety cross reviews, annual learning reviews, supervision, reflective practice meetings, team meetings, competency checks and governance systems.

The provider’s annual learning review identified themes relating to medicines management, incident categorisation, Mental Capacity Act 2005 (MCA) practice and management of equipment refusals. Leaders implemented service-wide improvements including strengthened medicines governance, revised recording processes, enhanced oversight of dietary risks, improved incident monitoring and stronger MCA review arrangements when people declined equipment or support. This demonstrated learning was analysed, translated into action and used to improve practice across the organisation.

Learning was also embedded at frontline level. Staff described a culture where concerns were openly discussed and used to improve practice. One member of staff said, “My manager informs us and gives advice. Learning is shared with other carers so we can improve, and incidents are recorded on a public scoreboard."

Managers described reviewing incidents daily, discussing incidents within management meetings and communicating learning through team meetings and digital communication systems so lessons could be shared quickly across the organisation.

The head of care told us, “When we identify an error, concern or area for improvement, we investigate it, learn from it and make changes where necessary." This approach helped ensure lessons learned resulted in sustained improvements to practice.

Reflective practice was used not only following incidents but also following bereavements and significant events. Staff attended reflective meetings following the deaths of people they supported and were encouraged to share learning, reflect on care delivered and identify how personalised interventions had positively influenced outcomes.

This approach ensured learning was translated into tangible improvements across the service, strengthening care quality, medicines governance, safeguarding practice and risk management.

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.

Leaders frequently acted as coordinators between hospitals, community services, social care professionals, therapists, general practitioners (GPs) and families. They anticipated barriers to safe transitions and personally intervened to prevent delays, gaps in care and avoidable deterioration.

For one person, the provider worked closely with family members and the receiving care home to support a safe move into long-term care. Care plans were shared before admission, verbal handovers were offered and detailed discussions took place regarding personal preferences, belongings, routines and arrangements for the journey. The provider remained actively involved until the transition was completed.

Rather than focusing solely on the safe transfer of information, staff worked to maintain continuity of relationships, routines and personalised support during periods of change. This reduced disruption and helped people experience consistent, person-centred care when moving between services

People experienced continuity because staff worked collaboratively with other organisations and proactively shared information to reduce risks during periods of change.

Relatives told us staff worked with families and receiving services to ensure support remained consistent when people moved between services. Information about preferences, routines and support needs was shared to help maintain continuity and reduce disruption.

People experienced continuity, avoided unnecessary delays, remained in their preferred place of care and received coordinated support from multiple agencies working towards shared outcomes.

The provider worked well with people and healthcare partners to fully understand what being safe meant to them and the best way to achieve that. Staff had a clear focus 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 always shared concerns quickly and appropriately.

Safeguarding was embedded throughout the culture of the organisation and closely linked to human rights, positive risk-taking, MCA and person-centred care.

Leaders consistently reinforced safeguarding responsibilities through supervision, training, spot checks, competency assessments and direct support. Managers described safeguarding as everyone's responsibility and encouraged staff to trust professional curiosity and speak up when something did not feel right.

The provider had invested significantly in MCA and human rights practice. Dedicated Mental Capacity and Human Rights Champions promoted rights-based practice, supported staff decision making and audited MCA compliance. For one person, the provider responded to an ongoing safeguarding concern relating to moving and handling. The provider introduced additional support visits to monitor practice, encourage safer transfer methods and gather evidence about the most appropriate support arrangements. Risk assessments were updated and staff were provided with clear guidance on balancing safety with the person's wishes. This demonstrated a proactive safeguarding response which protected the person from avoidable harm while promoting choice, dignity and least restrictive practice

There was extensive evidence of MCA being applied appropriately. For example, a best-interests decision regarding covert administration of medication for a person followed completion of a capacity assessment, including consultation with healthcare professionals and family involvement. Leaders demonstrated clear understanding of proportionality and least restrictive practice.

Staff had completed safeguarding training and knowledge checks demonstrated strong understanding of safeguarding, MCA, restrictive practices and consent principles.

External stakeholders confirmed safeguarding effectiveness. A professional told us safeguarding concerns were managed “thoughtfully, swiftly, and with great compassion" and described Kingsmith Care as highly responsive to concerns.

Another professional told us, the organisation recognised concerns promptly and acted appropriately, giving their confidence that staff understood safeguarding responsibilities and escalation procedures.

Relatives also expressed confidence in the provider's ability to keep people safe. One relative said," Absolutely, 100%" when asked whether their family member was safe with the care provided. Another commented, “We are very happy [person] is in safe hands."

People were protected from abuse and discrimination while maintaining autonomy, human rights and involvement in decisions affecting their lives.

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 consistently sought ways to enable rather than restrict people. Risk assessments demonstrated creative approaches which supported people to continue activities that were meaningful to them despite identified risks.

For one person, rather than restricting community access because of mobility risks, the provider developed a detailed risk assessment allowing continued independent use of their mobility scooter. Risks were identified, mitigated and monitored, while preserving an activity described as “the highlight of their day."

Information shared with staff demonstrated that the team was encouraged to support positive risk-taking and recognise that unwise decisions do not necessarily indicate a lack of capacity. Staff were expected to promote autonomy, uphold dignity, and adopt the least restrictive approach when supporting people.

Relatives confirmed they were involved in discussions about risks and future safety arrangements. One relative said, “Yes. We have talked about the falls and increased supervision”. Another relative described how staff had completed a review of the home environment, stating, “They did an inspection of our house to review everything inside and out."

The service repeatedly demonstrated a willingness to adapt risk management to individual circumstances rather than adopting blanket restrictions. Risk management arrangements helped people maintain independence, participate in activities that mattered to them and remain safe

The provider maintained safe environments and responded proactively when environmental risks were identified.

Managers conducted home assessments, sought specialist equipment and worked with occupational therapists and equipment providers to support people's safety and independence. Examples included the provision of hospital beds, crash mats, specialist seating, pressure-relieving equipment and adjustable tables.

Environmental risks were reviewed when people's needs changed, and staff worked with healthcare professionals to identify adaptations that reduced risks associated with deterioration and reduced mobility.

The provider also considered environmental sustainability through rota planning that reduced travel and promoted localised care delivery.

People were supported in environments that were generally safe, adapted and responsive to their needs.

The provider had robust systems to ensure there were sufficient skilled, competent and supported staff to meet people’s needs safely. Recruitment processes included thorough pre-employment checks, induction, shadowing, competency assessments and feedback from people receiving care before staff worked independently. Staff confirmed they received comprehensive induction, shadow shifts and access to clear care plans and risk assessments.

Leaders demonstrated a strong commitment to workforce development and career progression. Several senior leaders had progressed internally from care assistant roles into management positions, supported through funded qualifications, leadership training and mentoring. Staff were encouraged to develop specialist skills aligned to people's needs and their own interests.

Comprehensive systems were in place to monitor competence, including supervision, appraisal, reflective practice, medicines competencies, spot checks and team meetings. The provider maintained detailed oversight through workforce monitoring systems and acted promptly where training or competency gaps were identified.

Spot checks demonstrated staff delivered care safely, respectfully and competently, maintaining people's dignity, promoting independence and following safe working practices. Learning from observations was shared to continuously improve practice.

Workforce planning promoted continuity of care through careful matching of staff to people's preferences, needs, skills and compatibility. Long-standing staff enabled people to build trusting relationships with carers who understood their preferences, routines and communication needs. This contributed to continuity of care and reduced the need for people to repeatedly explain how they wished to be supported.

Rotas identified designated cover arrangements to minimise disruption and maintain established relationships.

Staff consistently described feeling well supported. One member of staff told us, “The best thing is the support from managers; I never feel that I am on my own.”

The impact of these arrangements was reflected in workforce stability and continuity of care. The service employed 52 staff with 15 staff with over 5 years’ service and 8 staff with over 10 years’ service, providing substantial organisational knowledge and experience.

Overall, leaders demonstrated strong workforce planning, investment in staff development and effective competency assurance, creating a stable and supported workforce that consistently delivered high-quality, person-centred care.

The provider maintained effective systems for Infection Prevention and Control (IPC) and control through audits, spot checks, staff guidance and competency monitoring.

Managers undertook IPC audits within people's homes and reviewed hand hygiene, Personal Protective Equipment (PPE) use, waste disposal, environmental cleanliness and staff understanding of infection prevention. Staff received training in infection prevention and control and completed refresher training to maintain competence.

The provider reinforced IPC expectations through staff communications, guidance updates and team learning. When minor shortcomings were identified, action was taken immediately. For example, shortages of PPE were identified during spot checks and addressed promptly.

Observational audits demonstrated high levels of compliance and provided assurance that infections risks were appropriately managed.

The provider had a proactive and person-centred approach to medicines management which promoted safety, choice and effective oversight. Medicines arrangements were regularly reviewed and supported through risk assessments, audits, competency assessments and involvement of relevant representatives and healthcare professionals.

Records showed people received medicines support tailored to their needs and capacity. Where people lacked capacity to make decisions about medicines, appropriate Mental Capacity Act 2005 processes were followed. For one person, a decision-specific mental capacity assessment concluded they were unable to safely manage medicines independently because of living with dementia. A best interest process involving their Lasting Power of Attorney resulted in medicines being securely stored and administered by care workers to minimise the risk of medication errors and accidental overdose.

The provider maintained strong oversight of medicines administration through electronic medicines administration records (eMAR). Reviews of eMAR records showed consistent recording of prescribed medicines, nutritional supplements, creams and “as required” (PRN) medicines. Medicines administration gaps were identified through governance systems and investigated. Records showed apparent omissions were reviewed, explained and evidenced through medicines gap analysis processes, providing clear audit trails and reducing the risk of unidentified errors.

Medicines practice was monitored through competency assessments and observation of staff practice. Spot checks showed staff followed medicines procedures, obtained consent, completed necessary checks and accurately recorded administration. Specialist competencies were also maintained for staff undertaking more complex medicines-related tasks, including administration through percutaneous endoscopic gastrostomy (PEG) systems.

Leaders used governance systems to review medicines performance and drive improvement. The annual learning review identified medicines-related themes, resulting in retraining, strengthened oversight and improvements to recording processes.