Kirkwood Court Also known as 1-143250927

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 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 did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The provider had systems for logging and investigating falls, incidents, accidents and safeguarding concerns. However, the provider had sometimes not acted robustly to learn lessons and resolve issues, such dealing with laundry concerns which the provider was aware was having a significant impact on people and staff.

The provider worked well with people and healthcare partners to establish and maintain safe systems of care. They managed or monitored people’s safety. They made sure there was continuity of care, including when people moved between different services. The provider had assessed people’s needs when they moved to Kirkwood Court, this information was used as a starting point to plan people’s care.

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. Safeguarding concerns were reported and investigated. Staff had completed safeguarding training and knew how to identify and report potential issues. The concerns raised relating to DoLS conditions had been addressed and DoLS authorisations were in place for all relevant people. This included supporting people to access the local community. People confirmed they felt safe living at Kirkwood Court. A person said, “I always (feel safe), it’s a great comfort knowing someone is there if I need them.”

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. The risk information section of care plans had not been completed consistently, despite care plans containing information which identified potential risks to people’s safety. Where risk assessments had been completed, these lacked sufficient detail to provide reassurance people were safe. The provider was in the process of reviewing care records to ensure these were accurate and reflected people’s needs.

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 provider regularly carried out risk assessments and health and safety checks, to help maintain a safe environment.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, and development. They did not always work together well to provide safe care that met people’s individual needs. Some staff had not completed essential training, such as food hygiene and fire safety. People and relatives gave mixed views about staffing levels. Staff told us they had been through a difficult patch with regards to staffing and support, but things were now improving. One staff member commented, “Staffing levels are better now than compared to before.” Staff told us they received good support. A staff member said, “The management are good, they are supportive. [Manager] and [Deputy manager] are very supportive, very approachable.”

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 home was clean and well maintained throughout.

Systems were in place to make sure people’s medicines were administered safely. Stock balanced with records. People’s medicines allergies were recorded accurately. A system was in place to record the actual time of administration for paracetamol although some doses for one person had been given too close to the previous dose without the recommended gap and some antibiotic medicines had not been given before food as directed.

We observed medicine administration to 2 people; staff were respectful, and people were given the time they needed.

Some people were prescribed medicines to be taken on a ‘when required’ basis or with a variable dose. Information for how these medicines should be administered needed further person-centred detail.

For creams applied by care staff as part of personal care; some guidance was missing, and records were not fully completed. Patch application records were not fully completed to show rotation in line with manufacturers guidance to prevent side effects.

Medication care plans needed further information or updating when changes occurred.

Medicines were stored securely including controlled drugs. Temperatures were recorded for the medicine rooms and fridges; however, the fridge maximum temperature had been out of range and had not been investigated to ensure medicines were safe to use.

Comprehensive policies and procedures were in place to support the administration of medicines. Audits had picked up some of the issues and an action plan was in place.