Kingswood 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. This is the first assessment for this service. This key question has been rated inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulations in relation to people’s safe care and treatment and safeguarding.

This service scored 38 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice. Concerns had been raised regarding the service from partner agencies, and the service was in organisational safeguarding. Records regarding incidents at the service were of poor quality and did not lead to any meaningful reflection or improvement activities. For example, where incidents of restraint had taken place there was limited or no evidence of learning from these events. Staff did not follow the provider’s own policy in relation to learning from incidents.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety well. They did not make sure there was continuity of care, including when people moved between different services. There were deficiencies in people’s pre-admission assessments. Important information about people’s needs and preferences were not used effectively to ensure people received the care and support they needed, in the correct environment. People’s relatives and visiting professionals of the services raised concerns in relation to communication, examples were given of information given to staff which was not passed on to relevant people to be acted upon.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Records relating to restrictive practices at the service were poor. Where incidents were recorded, they lacked sufficient detail for managers, other professionals and inspectors to be assured staff were following correct processes and were working in the least restrictive way possible. Minimal evidence was available to demonstrate that the service was working to reduce and mitigate the need for restrictive practices. Staff were not following the providers own policy in relation to completing learning from incidents. The provider could not demonstrate that recordings of incidents were used in any meaningful way to monitor the effectiveness or safety of the service. The service had been placed into organisational safeguarding by commissioning bodies. Although the service was working to improve, improvements had not been embedded at the service and prior to the inspection progress had not been completed at sufficient pace.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Feedback from people at the service and most relatives was poor, people did not feel listened to. Although evidence showed review meetings did take place which included people and relatives, people felt their feedback to the service did not change practices within the service. A relative told us, “There is no joined up care, nurses sometimes give jobs to support workers which they don’t know how to do, no-one takes responsibility. Professionals come to meetings but none of them are involved in the care, there is no core group of staff.” A person told us, “I’m not really involved in my care plans, I haven’t been asked.” People’s care plans did not always include important assessments. For example, a person who required support with their physical health did not have an assessment in place to determine their own capabilities in relation to managing these needs.

The provider did not always detect and control potential risks in the care environment. The service did have a maintenance person who undertook routine monitoring of safety within the building of, for example, fire safety, portable appliance testing and general maintenance. These checks were up to date and robust. However, risks to people’s psychological safety and wellbeing within the service was not always addressed. For example, where people were sensitive to loud noises, control measures had not been adopted to ensure they had access to quiet spaces to meet their sensory needs. Some work had been commenced in regards sound proofing of rooms, however this was not fully completed. This was an ongoing issue, and the provider had failed to address this within a timely manner.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs. Recruitment was completed safely. Not all staff had received training to meet the complex needs of people they supported. For example, the provider could not assure us nursing staff on duty had the required skills to meet people’s physical health needs. The provider did take immediate corrective actions to address this issue, however there was no evidence prior to inspection the provider had worked to ensure there was an adequate matching of staff skills to people’s needs. Staff at the service did not demonstrate a robust understanding of how to work with people to minimise and reduce risks. There was no evidence of staff practice being observed and monitored to support learning and improvement. Supervision had not taken place in line with the providers policy. Although this had been identified by leaders as an area which needed to improve, and some steps had been taken towards strengthening this area, these improvements were not fully embedded and some records requested by inspectors could not be produced.

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 tidy. Staff had access to adequate stocks of personal protective equipment (PPE) and were trained in how to use this correctly. The furniture at the service was clean and in a good state of repair with no visual signs of surface area damage which would impede effective cleaning. Staff and people had access to a laundry room with a functioning washing machine and tumble dryer.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Some areas of medicines were managed safely, for example, controlled drugs were correctly managed and weekly audits of medicines took place. However, we could not be assured the provider had always ensured staff had the correct training to enable them to safely and confidently administer some medicines people at the service were prescribed. During the inspection the provider was asked to take immediate actions to rectify this and leaders at the service acted promptly to address the concerns raised.