Kenrick Centre Also known as Delroy Bonnitto

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 66 (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 did not always have a proactive and positive culture of safety. Lessons were not always learnt to continually identify and embed good practice.

The provider did not have a robust system to learn lessons from previous experiences to improve the service. For example, audits were not robust and the registered manager did not have full oversight of how audits were conducted and lessons learnt from any concerns. Staff conducted audits on their own work, and this was reviewed by unit managers who reported concerns to the registered manager. This meant that the registered manager did not have full oversight of the care plan and medicines quality systems. This could place people at risk, should the registered manager not be aware of any trends in areas such as medication errors.

However, our inspection did not find any errors due to poor auditing. The registered manager made changes following our feedback and has implemented an action plan that is robust and has provided us with assurance that audit systems will be improved

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.

A social work professional confirmed this by saying, “This is a good home, the [registered manager] always makes appropriate and timely referrals and seeks help when needed with good communication.” Staff said information was shared with them.

Information was obtained from people, and others involved in their care, about people’s individual needs and risks to their safety. This was used to develop individualised care and risk management plans to ensure people received safe and appropriate care. Staff knew people’s care needs and associated risks well. Staff monitored people’s changing needs closely and reported changes to senior staff so appropriate referrals could be made to the relevant agencies. There was information risk assessment in place, to provide hospital staff with important information about the person and the health needs in the event of hospital admission, and some updating of these documents was taking place.

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.

We observed that people were comfortable and at ease with staff. The atmosphere at the service was calm, relaxed, friendly and homely. Staff were attentive and alert to any changes that might indicate people needed support for any anxiety or discomfort they might be experiencing. A relative told us, “[Person’s name] are safe and well cared for. Staff know what to do if they are upset or unhappy about something.” Staff had received appropriate Safeguarding training and were able to tell us how to report any concerns as well as understanding their own responsibilities. the registered manager had considered people’s needs during the initial assessment and at reviews with those who had a social worker. At the time of the inspection the home had 3 people living under Deprivation of Liberty Safeguards (DoLS) with 1 persons application being processed. The registered manager was managing DoLS effectively and consistently. However, we saw that not all best interest decisions had been reviewed in a timely manner. When we discussed this with the registered manager, they completed reviews within the inspection period.

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.

The registered manager and their senior team worked with people to understand and manage risks. A family member told us, “[Name of unit manager] always discusses risks with us such as going outside and how they will manage any issues.” People had care plans reviewed with them and their families in a manner that was inclusive and easily understandable. For example, simple language was used such as, ‘I will ask my support worker for headache pills if I get a headache’. People who left the service for days out with family had risk assessments which included details of family members contact details and emergency contacts.

The provider made sure equipment, facilities and technology supported the delivery of safe care. However they did not always detect and control potential risks in the care environment.

We found that an access cupboard door had been left unlocked. This meant that people have access to areas that could potentially cause them harm. We also found that there were fridges within the home that had unlabeled milk and other food items. A lack of labels could mean that staff were giving food to people that may be out of date. We also found that staff were placing food in a staff fridge that people could have access to. These foods could cause allergic reactions or other health issues if ingested by people with allergies.

However, the registered manager took action during the inspection and moved the staff fridge and ensured labels were placed on all food after we highlighted the issue.

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.

Staff had enough time to provide people with the care and support they needed. Managers made sure people received care and support from the same staff where possible to maintain consistency in people’s care and support and daily routines. Staff were supported with their learning and development needs and encouraged to continually improve in their role. The provider operated safe recruitment practices and only suitable staff were employed to work at the service.

A relative told us, “[Person’s name] is very well looked after, by excellent staff who know their needs well.” A person told us, “The staff are caring, kind and very approachable. They are easy to talk to and make me laugh. I love to have a laugh and joke with them.”

Staff understood and managed risks. We saw from staff files that staff received competency reviews on an annual basis and all training was complete and detailed. However, some staff told us that refresher training or additional training was not always available. The registered manager told us that some refresher and additional training had been paused due to internal changes within the organisation, however all mandatory training was within date. Staff were very supportive of the values of the service and the registered manager. One staff member said, “This isn’t just a job. It’s like my family. The management team work with us to get the best out of us for the people we support.”

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.

We saw that staff wore appropriate Personal Protective Equipment [PPE] when they completed care tasks such as providing food, medicines and personal care. There was a sufficient stock of PPE available and relatives who visited were supplied with PPE as required.

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.

Reviews of medicines were made by staff on a weekly basis including checking the Medicines Administration Records [MAR] for accuracy. We also saw that audits were conducted by senior carers and not the registered managers or senior management team. Staff competency was reviewed in accordance to policy and no errors were found. People were prescribed ‘as needed’ (pro re nata PRN) medication by their doctor. However, not all these medications had PRN protocols in place providing dispensing staff with clear instructions on what signs to look for as well as how to monitor any increase/decrease of the use of these medications. The registered manager explained that due to the rehabilitation wing of the service having regular doctor and nurse visits, they did not feel that all PRN protocols were required. They understood that although staff were experienced in most PRN medications, it was good practice to have protocols for all medications so that new staff or unfamiliar medicines could be managed safely. The registered manager implemented a PRN audit and advised that they would have PRN protocols completed urgently.

We also saw that medicines were kept in people’s rooms within locked cupboards in blister packs. However, during the recent hot weather with temperatures above 25C, there was no evidence of managers or staff taking action to ensure medicines were kept at a temperature that was within recommended guidelines.

However, the registered manager took action and ensured that an action plan included monitoring ambient temperature to ensure medicines were kept at the required temperature.