Kingswood Court Care Home

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 requires improvement. At this assessment, the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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 ensured there was a system for reviewing safety events. This included falls, accidents, near misses and incidents involving staff. Actions were taken where necessary to make improvements or keep people safe. Systems were in place so lessons were learnt to identify and embed good practice. Managers understood their responsibilities and made relevant partners aware of accidents and incidents, as necessary.

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’s needs were assessed before people moved into the home. The management team had a clear understanding of the individual needs they could and could not meet, ensuring people could experience positive outcomes. Where people had more complex care and support needs, there were systems for admissions to be agreed upon. This promoted people receiving safe support throughout their care journey.

Regular reviews of people’s care took place. People and relatives involved with their care were invited to attend. Where people’s needs had changed whilst living at the home, review meetings were held and staff looked at ways to support people. This included increasing care, providing alternative equipment, making referrals or seeking alternative care if the accommodation was no longer suitable.

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.

Staff understood potential safeguarding concerns, risks, and actions they would take. They felt people were safe living at the home. Staff knew how to access policies and information about safeguarding. We asked staff how they would report any concerns. One staff member told us, “I would go to the nurse, deputy, or the manager if I had concerns. I also know how to contact the local authority. I have no concerns.” Another member of staff told us, “I have no current concerns but have faith in my managers, who I go to and report anything.”

The registered manager maintained a log of safeguarding concerns they had reported or had been raised against the home. This contained information about the names of people, type of incident and the action taken. Records confirmed the home worked with the local authority safeguarding team to investigate any concerns raised. Investigation reports were maintained and where lessons had been learnt, this was recorded and actioned. The registered manager told us any learning was shared with the staff team.

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 had individual risk assessments to protect them when receiving care and support. Staff reviewed risk assessments when people’s needs changed, on a monthly basis and when they were the ‘resident of the day.’ This is where a ‘resident’ is chosen to receive special attention, focus, and celebration for a day, promoting their well-being and ensuring their clinical care needs are met. We looked at a sample of records and reviewed food, fluid, and repositioning charts. We found improvements had been made since the last inspection. People at risk of malnutrition had assessments which outlined the measures to reduce the risk.

Staff had a good awareness of people’s care plans and risk assessments, and they could be accessed at any time. In addition, staff found handovers helpful and meant they had up to date information about any changes to people’s needs or the risks they faced.

Staff felt they knew people well and had training to support people who expressed their needs, emotions, or distress in different ways. One staff member told us, “I check people’s needs on my work device if I am unsure. We are able to record information straight away. This included when changing people’s position in bed or when conducting wellbeing checks.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The home was designed to best meet the needs of everyone who lived there. There had been significant refurbishment of the building, with new décor, furniture and fittings installed. Communal areas were decorated and furnished to a high standard, and people could personalise their rooms. People had access to pleasant outdoor spaces which were secure. The refurbishment project had been carefully managed to minimise disruption, risks, or distress to people. The changes meant people lived in a safe and pleasant environment that was designed to meet their needs.

The provider had effective systems to proactively manage the safety, maintenance and repair of facilities, premises, and equipment. Regular servicing and maintenance were in place, and repairs were conducted in a timely manner. We reviewed records and certificates and found these were consistently completed and reflected current guidance and standards. There were effective fire safety procedures and exits and equipment were regularly checked and maintained. Qualified professionals completed specific environmental, and equipment checks to ensure these remained safe and met required standards. Managers oversaw the safety of the premises and equipment.

The provider made sure there were enough qualified, skilled, and experienced staff, who received effective support, supervision, and development. Staff were suitably experienced, competent, and able to carry out their role. There were appropriate staffing levels, and a good skill mix which meant people received safe care that met their needs.

Staff worked together to provide safe care that met people’s individual needs. They told us there were usually enough staff on each shift, and bank staff were used to cover short notice absence. Staff comments included, “I feel we have enough staff, and we work together to cover shortfalls. Another member of staff told us, “We do have enough staff, sometimes if there is sickness it can feel short. However we are told we have been over staffed due to the occupancy being lower, and the levels are safe.” Staff rotas reflected people’s assessed needs. There was a calm atmosphere on each floor, and staff responded to people’s needs in a timely manner. Staff took time to speak with people, and we observed many positive interactions during our visit.

Staff received induction and ongoing training which was appropriate and relevant to their role. This was embedded into practice and training was regularly updated and staff competency checked. Staff at all levels had opportunities to gain experience and develop further. Staff received the support they needed to deliver safe care. This included supervision, appraisal, and support to develop and maintain standards. Staff told us they received regular supervision and felt able to approach senior staff if they had concerns or suggestions.

There were effective and safe recruitment practices, and relevant checks were carried out before new staff started working at the home. The management team addressed poor staff performance to ensure people received a safe, high-quality service.

Staff assessed and managed the risk of infection in line with current relevant national guidance. They detected and controlled the risk of infection spreading and shared concerns with appropriate agencies promptly.

People were protected from the risk of infection and premises and equipment were kept clean and hygienic. The home was visibly clean, and a team of housekeeping staff ensured all areas of the home were cleaned to a high standard. They kept records to evidence regular cleaning took place.

The deputy manager was the lead for infection prevention and control. All staff received training to ensure they understood their responsibilities and standards were maintained. Regular checks of staff compliance were carried out, such as monitoring hand hygiene. We saw staff using personal protective equipment (PPE) appropriately and this was available throughout the building.

The provider took action promptly when the risk of infection was detected. Staff followed measures to manage and control its spread. Where there had been outbreaks of infection, clear guidance was followed, and information shared appropriately with external agencies, people, and visitors. People were supported to understand and follow infection prevention and control measures. Policies and guidance helped staff ensure they complied with current best practice.

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 stored securely within the home. The temperature of the medicine's storage was checked regularly to ensure medicines were stored at the correct temperature. Medicines were kept in suitable quantities without large excesses. Accurate records were maintained of medicines received into the home, administered and disposed of. Medicine administration records (MAR) were completed as required.

Staff had received training and competency assessments to administer and manage medicines including more complex tasks such as insulin administration and catheter care. The home completed daily audits which were reviewed by the deputy manager. The deputy told us they had worked hard to oversee the medicines system and supported staff with learning and improvement. Where medicines errors had occurred, the deputy completed investigations and actioned any learning. The staff told us they found the deputy to be supportive with medicines administration. One nurse told us, “[the deputy] is brilliant at sharing learning, hands on and always keeps oversight of medicines.”