Kings Court Care Centre

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 78 (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 strong proactive and positive culture of safety, based on openness and complete honesty. Leaders actively listened to concerns about safety and thoroughly investigated and reported safety events. For example, leaders made amendments to their working hours to enable them to be present at different times during the day, meaning they were able to directly communicate with different staff and relatives. This supported a learning culture because it made it easier for more people, relatives and staff to raise any concerns so these could be learned from to improve practice.

Lessons were always learnt to continually identify and embed good practice. There was an in-depth process to review accidents and incidents, where, each month, trends were analysed, actions were recorded, and lessons were learned to reduce re-occurrence. This was effective as

there was a notable reduction in similar events occurring throughout the year, such as less falls. For example, in September 2024 there were 10 falls recorded, compared to July 2025 where there were only 3 falls recorded, and August 2025 where there were only 2 falls recorded.

Staff told us there was a strong learning culture at the service. For example, one staff member told us, “There’s a strong culture of collaboration. Information is shared clearly in handovers, team meetings and supervisions. Feedback from staff, families and residents is listened to. Ideas and lessons from incidents are discussed and used to improve care. Staff are supported with training and champion roles for better care quality.”

Leaders thoroughly investigated any concerns or complaints and responded appropriately, which included sharing any learning with staff. This was effective as there were no re-occurring themes within concerns or complaints received by the service.

Additionally, there was a system in place to report medicines-related incidents and foster a learning culture. Learning from previous incidents relating to medicines had resulted in changes to practice within the service. People and relatives felt able to raise any concerns and we were told of examples where leaders had taken action to address concerns.

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. People spoke positively about how the service supported them with hospital appointments and visits. One person told us, “The GP sorts that out [hospital clinic visits]. Staff here do come with me and arrange for me to be taken. So far so good.” A relative also told us, “[Person] has been in hospital a couple of times which the home has arranged transport, it was all sorted and a carer had [person’s] bag packed ready.” People had documents in place to support safe transitions into hospitals, which contained important information about people and their needs. Staff told us there was a clear process which worked well when new people moved into the service, which included a detailed handover of information prior to staff supporting them.

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. A process was in place for managers to review safeguarding incidents and to record actions taken and lessons learned, to prevent re-occurrence. Staff had received training in safeguarding and knew how to keep people safe. Staff told us they would report any safeguarding concerns and felt these would be thoroughly investigated by leaders. People appeared comfortable around staff during our onsite visit and told us they felt safe. Some people told us the reason they felt safe was because of the staff. One person told us, “There are lots of people here, which makes me feel safe.”

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. Staff supported people to manage their risks. A staff member told us, “I feel that the care plans are very detailed and person-centred that provides me with the information I need to manage risk effectively.” People told us they had access to equipment to support them to manage risks.

People had detailed care plans and risk assessments. However, one person’s care and support plan for a medical condition did not contain some important information, such as potential triggers to the specified condition. We raised this with the provider who addressed this during the inspection.

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 appropriate health and safety checks which took place at the service. Where actions had been identified, these were resolved. Staff knew the evacuation process in the event of a fire.

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. During our onsite visit, we observed staff were available to meet people’s needs. People told us staff appeared busy but did not raise any concerns. Staff were recruited safely and had received training appropriate to their role.

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 generally clean and odour free, however we observed some minor infection prevention and control concerns during our onsite visit. For example, we observed some food and drink debris inside a communal cupboard, which was accessible for people living with dementia. This put people at risk of foodborne illnesses. We also observed a small amount of chipped paintwork on a hand railing in a corridor during our onsite visit. We raised these concerns during the onsite visit and leaders told us there were already plans in place to address the chipped paintwork to improve the service’s ability to keep all surfaces clean. The manager also asked staff to clean the inside of the cupboards.

People, relatives and staff spoke positively about the cleanliness of the service. Audits took place and these were effective as we saw actions identified were resolved. There was a policy in place for staff to follow which was appropriate for the service and staff had received training appropriate to their role.

The provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. Medicines including controlled drugs were stored securely and safely at the service. We observed people being supported by staff to take their medicines in a person-centred and caring way.  Staff completed mandatory medicines management training and annual assessments were completed to ensure they remained competent. A system of medicines audits was in place at the service which supported continuous improvement. Care plans reflected people’s individual needs in relation to their medicines. Care plans also included appropriate medicines risk assessments.