Kingly Terrace

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 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.

There were clear systems in place to report and investigate all incidents, accidents and complaints. Staff and leaders learnt lessons from incidents and took action to minimise the risk of recurrence. Where people had an accident or incident, there were systems in place to assess what happened and what needed to be done to minimise it happening again.

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.

The provider worked well with people, families and healthcare professionals to maintain safe systems of care. There were clear processes in place to support safe admissions, transfers and ongoing care. People, their families and relevant professionals were involved in assessments to make sure care was planned appropriately from the start. Hospital passports and treatment escalation plans were in place to support safe transitions.

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.

The provider had a clear safeguarding policy in place. It explained how staff should report concerns, including when to involve external agencies. Staff and managers had completed safeguarding training and understood how to raise concerns and who to report them to.

People told us they felt safe and received care that met their needs. One of the relatives told us, “I know (relative) living in a safe place.”

Deprivation of Liberty Safeguards (DoLS) applications had been submitted as and when required, with a log used to monitor applications, their outcome and when any reapplications were due. The manager understood the DoLS process and knew when an application would be required.

The provider submitted statutory notifications as required and had systems in place to identify, record and respond to concerns. The manager understood their responsibility under the Duty of Candour and promoted an open and honest approach when things went wrong.

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.

There were systems in place to assess, manage and monitor risks to people. The manager showed a good understanding of risks throughout people’s care journeys and took a proactive approach to managing them.

Risk assessments covered key areas such as falls, nutrition and skin integrity. Risk assessments were used effectively to identify potential hazards. Care plans were detailed and provided staff with clear guidance on how to support people safely and reduce the risk of harm. These were regularly reviewed to ensure they remained up to date. People and their relatives told us they felt involved in decisions about their care and support. They said staff understood the support they needed and managed risks in a way that promoted their safety while maintaining their independence.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.There were systems in place to monitor the safety and maintenance of the building and equipment. Equipment used to support people was easily accessible and stored safely when not in use. The home was well lit, with clear signage and wide corridors that were free from hazards, supporting people to move around safely and independently.

During the assessment, we observed people moving around the home safely and independently where they were able. People's bedrooms were personalised with items that reflected their interests and preferences, helping to create a familiar and comfortable environment.Individual personal emergency evacuation plans (PEEPs) were in place, and regular fire drills had been conducted to ensure staff knew how to support people safely and effectively in the event of an emergency.A fire risk assessment had been completed by an externally accredited company in March 2026. Although few issues were identified, the provider had completed most of the recommended actions and was continuing to work towards completing the remaining actions.Essential checks of the premises and equipment had been completed in line with guidance. These included water temperature checks, fire alarm call point testing, emergency lighting, fire extinguishers, the chair lift, and gas and electrical safety checks.

The provider made sure there were enough qualified, skilled and experienced staff to meet people's needs. However, they did not always ensure staff supervision and recruitment records were maintained in line with their own procedures.

Staffing levels were sufficient to meet people's assessed needs during our visit. The service was using agency staff to support staffing levels while actively recruiting permanent staff to improve continuity of care.People and relatives spoke positively about the staff supporting them. One relative told us, "I do not know the difference between the agency staff and the regular staff. They seem like a good team." This showed the use of agency staff had not negatively affected the continuity of care people received.

Staff received regular training and overall training compliance was good. A small number of face-to-face training sessions remained outstanding; however, these had already been arranged.We found that staff supervision was not always taking place in line with the provider's policy. The provider acknowledged this and told us they had plans in place to complete outstanding supervisions and appraisals.

We found some recruitment records were incomplete. Some staff files did not contain application forms, complete employment histories, signed contracts or induction records. While we found no evidence that this had affected people's safety, the provider could not demonstrate that all aspects of their recruitment process had been consistently completed and recorded in line with their procedures. The provider acknowledged this and told us they were improving their record-keeping systems to ensure staff records were complete and up to date.

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 provider had an infection prevention and control (IPC) policy in place which staff could access. Staff had received appropriate training and demonstrated an understanding of how to use and dispose of personal protective equipment (PPE), such as gloves and aprons. We observed staff following good hand hygiene practices and using PPE correctly to reduce the risk of infection.

The home was generally clean and free from unpleasant odours. However, only a general cleaning schedule was in place, and there was no documented deep cleaning schedule. This was raised with the manager, who acknowledged the concerns and agreed to review staffing levels and cleaning hours immediately.

There was sufficient PPE and cleaning equipment available throughout the home. The manager was aware of where to access relevant guidance, including infection control and outbreak management, and understood when to escalate concerns to external professionals such as Public Health and people’s GPs where required.

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.

People were supported to make informed choices about their medicines. Where people lacked capacity, decisions were made in line with best interest principles and were clearly documented.The provider had a medicines policy in place, and medicines were managed safely. Regular audits were completed monthly, with actions taken to address any issues identified. Staff had received medicines training, and their competency had been assessed to ensure safe practice.

Medicines were stored securely, including controlled drugs, which were only accessible to authorised staff. Storage conditions were monitored, including room temperatures. Liquids and creams with a limited shelf life were appropriately dated when opened.

People told us they received their medicines when they needed them and were supported to take them safely. We saw medicines were stored securely and records were completed accurately, demonstrating safe medicines management.

Medication administration records (MAR) were completed accurately. The ‘as required’ (also known as PRN), medicines had clear protocols in place to guide staff. We checked medicine stocks and found they matched the service’s records.