KYN Bickley

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.

This was the first assessment since the service was registered with CQC. This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 69 (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.

The service had effective systems for reporting, recording and monitoring incidents and near misses. These were regularly reviewed to identify any patterns or trends, and lessons learned were used to improve practice and reduce the risk of recurrence. There was a clear focus on keeping people safe.

Health and social care professionals were referred to for advice, as necessary. We received feedback from a health professional who said, “KYN Bickley has strong commitment to ensuring the safety and protection of residents, staff, and visitors. A range of proactive measures are in place to minimise risk and prevent avoidable harm, creating a secure and reassuring environment for all." Another health professional feedback was, “The provider is open to working with all health services, family and care services to ensure they protect residents in the best possible way."

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 and when people are admitted to hospital and liaising with other services.

Managers assessed people’s needs prior to their move to the service. This enabled them to identify the care and support needs people would require and make sure the necessary arrangements were in place to facilitate a smooth transition.

The provider obtained information about individual needs from people, and others involved in their care.This was used to develop individualised care and risk management plans to ensure people received safe and appropriate care and support from the moment they moved into the care home.

People and their relatives confirmed they were involved in the assessment of their needs. A relative told us, “I and my [relative] had a meeting with a manager to discuss [loved one’s] needs. The assessment was thorough.”

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.

People were supported by staff who had the knowledge, training and confidence to identify safeguarding concerns and take appropriate action to protect individuals from harm or abuse. Staff understood safeguarding procedures. They reported concerns to the relevant authorities when required.

Staff were able to explain the signs and what they would do if they suspected abuse.

Leaders understood their responsibilities in relation to reporting incidents to the relevant bodies, such as the local authority’s team and the Care Quality Commission. Staff knew how to access the provider’s whistleblowing procedure and relevant policies.

A relative told us, “[Person] is safe she is treated well and seems happy.”.

People told us they felt safe. One person told us, “It’s nice here. I feel safe here the staff are always around.” Another person told us, “I’m safe and they look after me here”.

The service had systems to protect people from abuse and neglect. The service had whistleblowing and safeguarding policies and processes in place which were available in different formats. The provider shared concerns appropriately with the relevant authorities. The provider worked with the local authority and other agencies when concerns were raised.

The provider requested legal authorisations where restrictions amounted to a deprivation of liberty for people who did not have the capacity to consent to these. However, they did not have effective systems to monitor conditions which were imposed as part of these authorisations. This meant there was a risk of unlawful restrictions. We discussed this with the registered manager who agreed to take action to address this.

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 provider undertook assessments to identify risks to people and to the staff who supported them. Family members and person told us they participated in this process. Staff supported people to manage risks whilst maintaining their independence by promoting positive risk taking. The registered manager told us how they balanced risk with people’s choices and rights. They told us other professionals were involved in helping manage risks. There were sufficient risk assessments in place in relation to supporting people who were at risk of mental health decline.

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 environment was safe, clean, and well maintained. The provider ensured checks on the health and safety of the environment, and fire safety, had been completed. People told us the home was “very clean and tidy” and “homely.”

Another person said, “I had requested replacement blinds for my bedroom window as they were faulty. Within an hour, new replacement ones were put up no fuss, no chasing”. A family member said, “My [relative] has always been a very tidy person, and the staff always keep their room nice and homely”.

Health and safety and fire safety risk assessments were place; we observed actions from these had been completed. Equipment was assessed and maintained to ensure people’s safety. For example equipment such as lifts, hoists and those related to fire and gas safety had been inspected in line with requirements. Each month safety checks were completed on equipment used to support people, such as specialist beds, call bell systems, wheelchairs and walking aids.

Personal evacuation plans were in place. These had been regularly reviewed to reflect people’s support needs in the event of needing to evacuate the building in an emergency. Staff told us they had received fire training in person and records supported this.

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.

people’s needs were met and staff did not rush. Staff were not rushing. There was a process in place to assess staffing levels based on people’s dependency and needs. There were enough staff to provide safe consistent care. Rotas confirmed this.

People told us staff were there when they needed them. People and their relatives told us there was enough staff on duty, and they had the right skills to support them with their needs.

Comments from relatives included, “They’ve managed to get staff members who understand what [person] wants”” And “It takes 2 of them, to provide [relative] with the personal care, the staff never rush I know I’ve waited quite a while outside the room while the carers are providing care”.

Staff files showed staff were recruited safely, and recruitment records reflected this. Procedures were in place to ensure the required checks were carried out on staff including nurses before they commenced their employment. This included enhanced Disclosure and Barring Service (DBS) checks for adults. Staff learning and development was in place to ensure all staff were properly inducted into the service and their knowledge developed. Staff had been supported with career progression. The provider and manager had oversight of training within the service.

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.

A person said, “The house keeping staff are very good, I still make my own bed and dust too”.

The provider had procedures to help prevent and control infection. The provider had procedures to help prevent and control infection .

Staff were trained in infection control and followed safe procedures, including wearing appropriate personal protective equipment (PPE) when needed. The environment was clean and fresh, and there audits of cleanliness ensured by the IPC lead.

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, including controlled drugs (CDs), were stored securely.

People received medicines safely and as intended by the prescriber. Electronic Medicines Administration Records (MARs) were in place which provided staff with accurate information about the medicines. Each MAR profile included personalised details which explained how the person preferred to take their medicines. Medicines were administered in a timely manner and recorded on the electronic medicines administration record. Staff monitored people’s blood glucose when needed. Staff used charts to indicate the site of injections and ensure site rotation. Administration of patches was appropriately recorded on topical MARs. Medical equipment was periodically checked and tested.

Care plans had the necessary information to support people with their health needs and prescribed medicines. However, staff had not always assessed the risks relating to paraffin-containing emollients. Use of these creams can increase the flammability of clothing and bedding. This was brought to the attention of the clinical lead.

Staff had assessed other risks relating to medicines. The service had an auditing and stock management system which provided assurances that medicines were being given safely and as prescribed. Where errors were identified learning and improvement from these was implemented and embedded into practice by the service.