Kingly 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 inspection we rated this key question requires improvement. At this inspection 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 service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and staff had received additional face to face training to support them and embed good practice. One person’s safe moving and handling had proved difficult, so the manager arranged for the occupational health team to reassess and implement a safe plan which requires 3 staff. A member of staff described how the staff team continually learnt from incidents and had improved safety and people’s experiences over the last 6 months, they told us, “We have more clarity of what is expected of us.”

The service 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. There was a system to ensure all key information about people were with them when they went to hospital. For example, a person’s notes gave staff clear instructions to ensure specific equipment to be with them when going into hospital.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They 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 service shared concerns quickly and appropriately and records showed the registered manager had followed the provider’s safeguarding policy. The registered manager was the safeguarding lead and ensured all staff had received safeguarding training and understood their responsibilities . Where people lacked capacity around specific decisions, the service assessed people’s capacity in line with the Mental Capacity Act 2005 and acquired the necessary legal authorisations to deprive a people of their liberty.

The service worked with people to understand and manage risks by thinking holistically. Staff had clear and accurate information about people’s risks. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them . A person told us they enjoyed being outside; they liked to go into the garden without their walking frame but they were not aware of the risks. Staff facilitated them to access the garden and mobilise without their frame by staying close and offering verbal guidance and prompts.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Regular safety checks were carried out on equipment such as wheelchairs, hoists and beds. The manager was proud of the changes made to improve the home; in addition to the redecoration and new furniture, the garden was now accessible to wheelchairs and the pond had been cleaned and repopulated with fish.

The service 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. The rotas showed and the registered manager told us, “I do the dependency tool and take on the routine of people, staff well-being I then come the conclusion of nearly 1:1.” Training records showed staff received specific training to provide for people’s individual needs. Senior staff received additional training and competency checks from health professionals to support them with extended tasks in relation to managing seizures, diabetes and administering medicines via people’s percutaneous endoscopic gastrostomy tube (PEG). A PEG tube is a plastic tube that allows people to receive nutrition, water, and medication directly into their stomach. One member of staff told us, “We work with health professionals to get the skills we need, the manager and everyone are very supportive.”

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The home appeared clean; staff carried out monthly audits to ensure all areas of the home were regularly cleaned. Staff hand washing competencies were checked and infection prevention and control procedures were discussed at every team meeting.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened. Specific staff were trained to administer the medicines; they had their competencies checked and received regular supervision. People received their prescribed medicines and staff recorded when and why people received their ‘as required’ medicines. Regular medicines audits were completed and actions had been completed to make improvements to the medicines management.