Kalm Living

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 changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to people’s safe care and treatment and safeguarding service users from abuse and improper treatment.

This service scored 41 (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 did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice

There was a lack of oversight of events happening within the service and therefore a risk action would not be taken to ensure people’s safety. Lessons were not learned to continually identify and embed good practice. There were no systems to support learning from incidents and accidents.

Records viewed did not consistently show there was a proactive culture regarding health and safety incidents or concerns, and that these had been effectively reflected upon and used to drive improvement.

Events across the service were not compared or audited. The registered manager did not have oversight of incidents across the service and was unable to identify any patterns or trends.

The provider did not always work well with people and health system partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

There were delays in seeking medical attention and poor escalation of risks to relevant health professionals.

We reviewed an incident report whereby a person had an unwitnessed fall in the hallway. Staff had recognised the person had hit their head during the fall. There was no head injury protocol to give staff guidance on how they should respond to suspected head injuries to ensure people’s safety.

We reviewed records of an incident where a person took someone else’s medicine. The person’s GP or 111 were not contacted. When the error was identified, a decision was made by staff, without seeking medical advice, to not give the person their own medicines at the time. There was no record of the person being monitored overnight and no evidence of any follow-up.

This did not demonstrate a service which managed and monitored people’s health conditions to ensure positive outcomes for people.

People’s hospital passports did not always contain up to date information. For example, one person’s medicines information was inaccurate. A hospital passport gives an overview of people’s needs and how best to support and communicate with them if they were admitted to hospital unexpectedly.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

People were not always protected from the risk of financial abuse. We reviewed records for February 2026, where staff had recorded when and how much money had been spent. However, there was no breakdown of what money was spent on. Receipts were saved, however, there were no internal checks of people’s expenditure. There were no audits or oversight of these records. This meant there was a risk discrepancies would not be identified.

The provider was also not working in line with their financial policy. We reviewed a policy named ‘financial policy’ which was not dated. This document stated, ‘All client’s finance records will be audited by a general manager on a regular basis.’ There was no evidence financial records had been audited at any point.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. 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 provider had not ensured care staff understood and worked within the requirements of the Mental Capacity Act 2005 whenever they worked with people who may lack the mental capacity to make some decisions. This placed people at risk of being unlawfully restricted and not upholding their rights. For example, a person had extensive restrictions in place at night. There was no evidence any mental capacity assessment had been completed to assess whether they could consent to these practices. There was no evidence these restrictions were the least restrictive option or in the best interest of the person. These restrictions were unlawful.

As a result of these restrictions, the Care Quality Commission made a safeguarding referral to the local authority.

The provider’s undated Mental Capacity Act policy contained limited detail. The policy failed to mention the importance of mental capacity assessments, best interest decision making and meetings and the importance of advocacy, including Independent Mental Capacity Advocates and health and social care professionals’ involvement.

There was a lack of effective systems and processes to monitor incidents and accidents. As a result, safeguarding concerns had not been escalated to the local safeguarding authority and CQC were not notified in line with legislation. This included incidents where the police had been involved and significant medicines errors. This placed people at risk of avoidable harm as incidents were not always investigated, nor actions taken to reduce the risk of incidents occurring again.

Staff received safeguarding training about the protection of vulnerable people. However, this was ineffective as necessary safeguarding referrals had not been made when significant incidents occurred.

People did confirm they felt safe with the staff that supported them.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

There was a lack of awareness of risks associated with people’s support needs. Staff did not always identify and manage risks proactively and effectively to keep people safe. Care and support was not always planned and organised with people, together with health and social care professionals, in ways that ensured continuity.

There was no choking risk assessment for a person whose care file stated they ate fast and was therefore at risk of choking.

On reviewing incident reports, a person had suffered 5 falls between April and October 2025. No falls risk assessment had been completed to mitigate future risk of additional falls.

One person sometimes behaved in a way which put themself at risk. On one occasion this had resulted in the police being called. There was no risk assessment or guidance for staff on how they could mitigate the risk or what action they should take to support this person and ensure their safety. There was no evidence any work had been done with the person to help them understand the potential consequences of their actions.

There was a lack of oversight by the provider of events happening within the service. When incidents occurred, they were not effectively reviewed to identify areas of learning and improvement, and action was not taken to improve people’s safety. This failure unnecessarily exposed people to risk of harm.

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.

Risks relating to the environment were not always identified or action taken to mitigate these risks. One person was unsteady on their feet and at risk of falling. There was no environmental risk assessment for this person to ensure risks in their environment were mitigated.

People were not always able to move freely around their homes and spend the day as they wished. People were not always able to access the kitchen without staff support. No consideration had been given to installing equipment to reduce restrictions. For example, one person was prevented from using taps as staff reported they often failed to turn them off. A less restrictive option would have been the installation of taps that automatically turned off. However, this equipment had not been requested by the care provider.

No environment audits were carried out to ensure the safety of people’s homes.

However, staff confirmed they had received relevant health and safety training, including fire safety, to carry out their roles to ensure people’s safety.

The provider did not always make sure staff received effective support, supervision and development.

Staff training was ineffective. Staff lacked the knowledge and skills to meet people’s support needs. The registered manager and staff did not understand the requirements of the Mental Capacity Act and had unlawfully restricted people’s freedoms. The registered manager had not identified safeguarding incidents and people did not receive safe, individualised care and support.

Supervisions were not meaningful. They did not provide opportunity to explore best practice and address areas for improvement. The registered manager acknowledged this and recognised they needed to be more formalised and structured. In addition, staff appraisals had not been completed with staff for 3 years.

The registered manager did not receive formal supervision to support them in their role and ensure they were working in line with current, evidence-based practice.

However, staffing numbers were sufficient to meet people’s needs and support was provided by a consistent staff team. This ensured people were able to build up trusting relationships with staff who knew their needs.

The service’s recruitment and selection processes were safe.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The provider’s infection prevention and control policy was not up to date and did not reflect current good practice guidance. The policy contained basic information and did not explain the signs and symptoms to look out for in regard to any specific illnesses and infections and how to manage them to ensure people’s safety. It did not provide contact details of agencies to contact in the event of an outbreak, for example Public Health England.

Staff supported people to keep their homes clean and tidy. People and their relatives did not raise any concerns about infection control. Personal Protective Equipment (PPE) was available for use when required.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Medicines management practices were not robust and did not comply with current best practice guidance. Staff had failed to seek guidance from health professionals following an incident where a person took another person’s medicines in error. A decision was made to withhold the person’s own medicine without professional advice and no additional, monitoring was completed to ensure the person’s safety. This had exposed the person to additional risk of harm.

The service was not following its own medicines policies as staff competency to support people with medicines had not been assessed. The provider’s medicines policy stated, ‘In support settings, people who are unable to manage their own medicines are entitled to have someone who is adequately trained and knowledgeable to give medicines to them. Only staff who have been given appropriate training and have demonstrated they are competent should do this.’ However, no records of medicines competency checks were available for staff in the service and one staff member commented, “We don't have to undergo any competency assessments in our role.”

No medicine audits were carried out to ensure people’s medicines were managed safely.

Some people had medicines available to use ‘when required’ (PRN). For example, for pain relief and anxiety. There were no PRN protocols to guide staff on when these should be administered and any possible side effects. This meant there was a risk staff would be inconsistent in their decision making around the appropriate use of PRN. Staff did not record whether PRN had been effective. Following the inspection the registered manager agreed to develop PRN protocols to be used where needed.