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. At our last assessment we rated this key question inadequate. At this assessment the rating has changed to 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 implemented improvements in how learning from incidents was undertaken. For example, staff were supported to reflect on incidents in their supervision sessions. Managers and staff worked together to mitigate risks and there had been a reduction in incidents at the service since the last inspection.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always make sure there was continuity of care, including when people utilised health and social care services. Improvements had been made at the service in relation to the sharing of information with people, relatives and professionals. However, some improvements were still required in this area. For example, professionals told us of recent information that was not shared with them in a timely manner. Relatives told us organisation at the service was much improved but did give some examples of miscommunication with the service, for example information about an appointment was not passed on to a person who uses the service. Managers gave assurances that information sharing would be strengthened at the service.

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. Staff at the service understood how to identify and report safeguarding concerns and records evidenced that when staff did this, managers took immediate and proportionate actions. The service had worked to implement improvements in this area, and records evidenced a reduction in incidents.
People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that the service worked in accordance with both MCA and DoLS guidance.
 

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. People and their relatives were invited to regular reviews about their care. Records evidenced that the service had worked to change their practices to make meeting people’s individual needs easier and less restrictive. For example, the service had changed their staffing rota to ensure people were able to get out and about into the community more often.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Building maintenance and fire safety systems were operated safely and in line with expectations. Some issues with environmental improvements were ongoing at the service. For example, there was a longstanding issue with inadequate sound proofing at the service which had previously caused distress a person at the service. The provider was completing ongoing work to manage this. However, records evidenced that the sound proofing issue was not having a significant impact on people living at the service at the time of the inspection. Some work had been completed to make the environment more homely and the management team demonstrated a commitment to continuing work in this area.

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 were recruited safely and received regular training to support them in their roles. The service had improved staff support and oversight. Staff received regular supervision with managers and were given the opportunity to reflect on and learn from incidents. Managers were available to lead and support staff and feedback from staff was positive. A staff member told us, “I always feel listened to and there is plenty of support.” The provider had ensured that staff skills were matched to the needs of people and there were adequate numbers of care and clinical staff available to meet people’s needs.

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. A regular housekeeping staff was in place to maintain standards of cleanliness. The provider had ensured that staff had access to appropriate stocks of personal protective equipment (PPE) and training was in place to ensure this was used effectively. Furnishings were in a good state of repair and people were protected from the risk of infection.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Medicines were mainly managed safely. One issue was found during the inspection. A person who required as and when medicines had not had these booked out to go with them when they left the service. No negative impact on the person was noted however this did create a potential risk to the person. The provider took immediate steps to rectify this issue and implement processes to ensure this was not missed in the future. Medicines were stored correctly, administered safely and records were completed in line with expectations. Staff had the correct skills and competence to manage medicines safely.