Kingfield Mews

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 good. This meant people were safe and protected from avoidable harm.

This service scored 72 (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.Processes were followed to ensure all accidents, incidents, safeguarding concerns and complaints were appropriately investigated and actioned. Lessons were learnt to continually identify and embed good practice.

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.

Assessments of people’s needs prior to moving in were carried out and the service sought support from the GP practice, and health and support team where necessary. We found staff and leaders made appropriate referrals to external professionals and staff followed their guidance. One family member said their relative’s move into the service was carefully planned and gradual. The children's home staff, school staff, and the provider worked together to support the process, and they told us the family was, "Absolutely involved throughout.”

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 systems and processes were in place to identify, report and investigate allegations of abuse. The management team were aware of their responsibilities to report safeguarding concerns and work with relevant organisations to ensure people were kept safe. Staff told us they felt comfortable to whistle-blow on poor practice, and they were confident the management team would listen to them and act.

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 appropriate DoLS applications had been submitted where required, and authorisations were in place. Records showed that conditions attached to authorisations were being met, and staff monitored these effectively. This meant the service was acting lawfully and protecting people’s rights while ensuring their care needs were met.

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 were encouraged and supported to take positive risks. This allowed them to live as unrestricted a life as possible. Staff we spoke with were aware of people's individual risks and shared with us how they used techniques to reduce the likelihood of people being harmed. Some people living at the service required support to manage difficult or distressed behaviours and staff received training and clear guidance about how to do this safely. Staff regularly evaluated and reviewed risk assessments to ensure they remained up to date and relevant to each person. The manager reviewed incidents and information about risks regularly. Care plans were updated to ensure staff had information about people’s current needs.

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

During the assessment, several environmental health and safety concerns were identified. Cleaning materials were found stored in COSHH (Control of Substances Hazardous to Health) cupboards which had been left unlocked, creating a potential risk of unauthorised access and exposure to hazardous substances. This presented a risk to people using the service, staff, and visitors. The provider responded immediately and secured the cupboards at the time of the inspection. We identified potential risks associated with the staircase area, we recommended the provider review and assess the risks associated with the stairs, including slips, trips, falls, handrail provision, lighting, and safe access arrangements, to ensure people using the service were protected from avoidable harm. The provider responded positively to environmental risks identified during the inspection and took immediate action where required.

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

During the assessment, several environmental health and safety concerns were identified. Cleaning materials were found stored in COSHH (Control of Substances Hazardous to Health) cupboards which had been left unlocked, creating a potential risk of unauthorised access and exposure to hazardous substances. This presented a risk to people using the service, staff, and visitors. The provider responded immediately and secured the cupboards at the time of the inspection. We identified potential risks associated with the staircase area, we recommended the provider review and assess the risks associated with the stairs, including slips, trips, falls, handrail provision, lighting, and safe access arrangements, to ensure people using the service were protected from avoidable harm. The provider responded positively to environmental risks identified during the inspection and took immediate action where required.

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.

Staff supported people in maintaining clean living environments and reducing infection risks. They had access to personal protective equipment (PPE) and completed training in infection prevention and control (IPC) which contributed to a safe and hygienic setting. One relative said, "It's always very clean."

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 were safely managed. There were safe systems in place to acquire, store, administer, monitor and dispose of medicines. People had their medicines managed safely by staff who were trained and competent. There was an effective system in place for ensuring medicines were accounted for and the records about medicines demonstrated that people were given their medicines and creams as prescribed. There were protocols for 'as required' (PRN) medicines such as pain relief medicines. This included recording why the medicine was needed, and if it had been effective when taken.