Kirby 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 good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 66 (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 registered manager told us that after each accident or incident, they conducted a review to determine what happened, why it occurred, and what actions could be implemented to prevent recurrence. The reflective process helps the provider to identify both what worked well and what needed improvement.

Throughout the assessment the provider was responsive when concerns were raised. For example, the registered manager responded by speaking with the catering team when a person raised concerns regarding the quality of their lunchtime meal.

Staff were knowledgeable about their role in reporting accidents and incidents. Staff told us when incidents had occurred, they were alerted to these at both staff handover meetings and via messages on handheld devices linked to the electronic care record system. A staff member said, “At handover it is explained what went wrong, and what is expected as part of lessons learnt.”

External agencies told us the provider responded where shortfalls were identified to promote people’s safety and wellbeing.

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.

An assessment was undertaken of people’s needs before moving to Kirby House for both long term and respite care. A relative told us, “He’s not been here very long. The move has been brilliant; they couldn’t have been more helpful.” A second relative told us, “I telephoned for a respite bed, the home have been very kind. The manager was very kind and reassured me.”

Referrals were made in response to people’s changing needs to both health and social care agencies in a timely and effective way. This supported people’s continued care, including when people transferred to other care settings or hospital, which included the sharing of information to support a smooth and safe transition. A health care professional told us, “The service does make referrals to our practice in an appropriate and timely manner. If there is an emergency that needs immediate attention, they will call 999 and they appropriately access the out of hours service if a patient is having a medical problem when the practice is closed.”

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.

Systems and processes were in place to document and monitor safeguarding concerns and Deprivation of Liberty Safeguards (DoLS), which were underpinned by policies and procedures. The provider shared concerns quickly and appropriately with statutory agencies in line with their responsibilities. Evidence demonstrated any conditions linked to people’s DoLS had been actioned. The registered manager told us, “We strictly follow the local authority safeguarding guidelines and thresholds to ensure that all concerns are appropriately assessed and reported.”

Staff had undertaken training on safeguarding, mental capacity and DoLS. They understood their responsibilities to protect people from abuse and harm and were aware of how to support them in their best interest when people did not have the capacity to make an informed decision.

People and their families spoke positively about safety and care. A person told us, “I’m safe. It’s a nice place.” A relative told us, “He’s safe here, he’s not had a fall for a long time. We haven’t raised a safety concern.”

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.

Risks associated with people’s individual care and treatment needs had been assessed and were regularly reviewed. This included the risk of developing pressures sores, swallowing difficulties and falls risk. Where risks were identified, a care plan and risk assessment were developed so staff knew what action to take to reduce any risk of harm. A relative told us, “She has a wheelchair and walking frame to help her walk. The home have managed risks very well.”

Where people were at risk of falls, assistive technology was used such as sensor mats to alert staff when people were moving independently, enabling staff to respond and provider support. Staff were knowledgeable about people’s identified risks. They told us they had access to people’s care records, and where required, used equipment to move people safely.

Guidance was in place for staff where risks associated with people’s health, which included when people experienced anxiety and distress due to dementia or mental ill health. Staff told us how they supported people during periods of distress, which was based on staff’s knowledge of how people responded. For example using distraction, which included encouraging a person to take part in an activity which they enjoyed, such as colouring.

The registered manager told us, “We actively encourage residents to make meaningful daily living choices that promote independence, dignity and sense of purpose. This sometimes involves positive risk taking, where residents are supported to engage in activities that may present minor risks but deliver emotional and psychological benefits. For example, assisting with laundry, helping with gardening, supporting with the drinks trolley and assisting with light cleaning tasks.”

The provider detected potential risks in the care environment. In the main they made sure equipment, facilities and technology supported the delivery of safe care. However, the timeliness of repairs and maintenance is an area which would benefit from improvement.

The provider had a service improvement plan which included repairs to the environment, including decoration. However, in some instances the target date set for achievement by the provider had not been met. Some improvements to the décor of communal areas, including small lounges had been completed. However, some areas remained outstanding, which included corridors, bathing and toilet facilities, bedrooms and large communal rooms. A relative told us, “The only suggestion for improvement I have is that the furnishing is basic. For example, in the conservatory there is a sofa which is very low, and a table that is too high for practical things. Once when I visited, my [relative] ate in the conservatory and he had to balance the tray on his knee.”

The registered manager informed us a facilities manager had recently been appointed which meant they had a dedicated point of contact for any environmental or maintenance concerns.

We observed equipment had been serviced and to be in good working order. Adaptations and equipment were appropriate to meet people’s needs, such as walk-in showers and handrails. The registered manager told us the service had 1 rotunda, which they had borrowed from a sister service. A person told us. “I am not able to walk so I cannot walk across the room; I need help to going to the toilet and they use a rotunda to get me up. There is only 1, and sometimes I have to wait a long time.”

Some people felt the environment was not suited to them due to its size. A person told us, “This is the biggest care home I’ve ever been in. There are too many people. I think I would be better off in a smaller quieter care home.” Kirby House, in addition to the main, large lounge had several smaller communal areas for people to sit if they chose, which were intimate and quieter. However, no one was using these rooms when we visited.

Fire risks were assessed, and staff completed fire safety training. Personal emergency evacuation plans had been completed, which informed staff and emergency services of how to support people to safely evacuate the building. Staff understood their role and responsibility in supporting people to evacuate the home in an emergency. A member of staff told us, “We often have fire evacuation scenarios. For example, what to do if someone will not leave their room. We’ve experienced being put on the evacuation sledge, so we know what it’s like.”

The provider made sure there were enough qualified, skilled and experienced staff to meet people’s personal care needs, who received effective support, supervision and development. However, staff from other departments sometimes undertook other roles in response to staff absence, which impacted on people’s experience. Staff worked together well to provide safe care that met people’s individual needs.

The provider used a dependency took to assess people’s individual care and support needs, which was used to determine staffing levels. People were supported by sufficient numbers of staff. We observed a visible staff presence was maintained in communal areas, ensuring people had prompt access to assistance when required. Throughout the day we observed staff respond in a timely manner to call bells and people’s verbal requests for assistance. Most staff stated there were sufficient staff to meet people’s needs.

Staff were employed in other key areas to support the day to day running of the service, which included housekeeping, laundry and catering. However, we received feedback from people, relatives and staff, that in some instances individuals employed to provide activities for people, including accessing the community were sometimes redeployed to support other areas of the service, which impacted on people’s experience.

People’s views and that of most relatives said there were sufficient staff, but commented as to how busy staff appeared. One person told us, “The staff are rushed off their feet, they don’t have time to deal with the little details.” A relative said, “I think there are enough staff; they are always busy.”

Staff were recruited in a safe way. Appropriate checks were carried out prior to people commencing work, to enable the provider to be confident suitable staff with the right skills and experienced were employed. Induction training was provided to new staff. A member of staff told us, “There is so much to learn about people. I shadowed [worked alongside] experienced staff for the first two weeks, everyone has different needs.” Staff completed training in key areas linked to people’s health, safety and welfare and were supported through one to one supervision and annual appraisals.

The provider assessed and managed the risk of infection. However, the timeliness of repairs and replacement of equipment would improve infection and control measures and reduce identified risk. Concerns were shared with appropriate agencies.

Staff had access to personal protective equipment, which included gloves and aprons. There were sufficient housekeeping staff on duty, who followed cleaning schedules in line with best practice guidance. Audits and checks confirmed health and safety assessments and ongoing monitoring procedures were in place. Improvements to the environment to support effective infection prevention control (IPC) had been identified by the provider, which included damage to the paint work of door frames, skirting boards and handrails.

We identified some damaged equipment which required replacement or repair. For example, we found peeling paint on both an item of moving and handling equipment and the grill cover of a shower. In addition we found 2 bed frames to be damaged, and exposed masonry in 2 bedrooms. All of which posed a potential IPC risk as they could not be effectively cleaned. The provider updated their service improvement plan to reflect the shortfalls identified, and submitted evidence following our site visit confirming the bed frames and damage to the bedroom walls had been addressed.

Staff were confident about IPC procedures and had undertaken training. A member of staff told us, “Infection control, it’s to protect ourselves and others, gloves, handwashing, cleaning. And not mixing soiled laundry with non-soiled”

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.

Systems were in place for staff to safely administer and store medicines. Records we checked showed people were having their regular medicines administered safely and on time. Medicine audits and checks were regularly completed and these confirmed where shortfalls had been identified, actions had been taken to make improvements. We found protocols for some medicines were not in place. The provider took immediate action by ensuring protocols were in place for all medicines. The provider had access to an out of hours pharmacy to ensure people always had access to essential medicines without delay.

People had individual medicine care plans that provided staff with important information such as any allergies, and any associated risks, for example those associated with taking blood thinning medicines.

Mental capacity assessments had been undertaken where people declined to take their medicine. When people were found not to have capacity to make an informed decision, best interest decisions had been made, which included the administration of people’s medicine covertly.

People were supported to have their medicines reviewed regularly by healthcare professionals. For example, a person’s medicines had been reviewed by their psychiatrist to promote the person’s health and wellbeing.

Staff had received training in medicines management, administration and had access to the provider’s policy and had their competency assessed. A member of staff told us that medicine errors were reported, and staff involved in errors had to undertake refresher training and have their competency reassessed before they could resume their role of medicine management and administration.