Kings Court

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

We assessed 8 quality statements in the safe key question and found areas of good practice. People and those important to them were supported to understand safeguarding and how to raise concerns when they did not feel safe. Staff understood their duty to protect people from abuse and knew how and when to report any concerns they had to managers. When concerns had been raised, managers reported these promptly to the relevant agencies and worked proactively with them, to ensure timely action was taken to safeguard people from further risk. Safety risks to people were managed well. Managers assessed and reviewed safety risks to people and made sure people, and those important to them, were involved in making decisions about how they wished to be supported to stay safe. There were enough staff to support people with their needs. Managers reviewed staffing levels regularly to make sure there were always enough suitably skilled and experienced staff on duty. Staff had not always completed relevant training. Staff received support through supervision and appraisal to support their continuous learning and improve their working practice. Managers made sure recruitment checks were undertaken on all staff to ensure only those individuals that were deemed suitable and fit, would be employed to support people at the service.

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.

People were empowered and given opportunities to speak up if they had a concern. People living at Kings Court felt improvements would be made to their care if needed. People told us that if an incident happened, staff included them in discussions, so it did not happen again.

Staff told us that they had regular reflective supervision sessions to review what was working well, and what could be improved at the service. Staff gave examples of how the staff team had learnt from incidents. For example, one staff member said, “we have staff meetings where we discuss any concerns or incidents.” The care manager told us they have monthly learning meetings with a range of staff from different roles and discuss incidents, learning, improvement, and actions from the last meeting. This meant there was a learning culture within the service.

There were clear and effective process in place to review incidents and then make improvements. Staff were provided with the opportunity to reflect after incidents to ensure learning and improvement could occur. Staff meetings allowed staff to reflect on what was working well, and what could be improved at the service. There was a clear policy on the duty of candour. This policy guided staff to tell the person (or, where appropriate their advocate) when something has gone wrong.

People told us that the communication between the care home staff and other health providers was of good quality. One person told us they had a smooth transition from hospital to the care home for respite care.

Staff had good knowledge of which health and social care professionals supported which people. Staff were able to explain when these professionals visited, and what type of support they offered. Staff knew how to monitor people’s health conditions to ensure timely referrals were made to other services. For example, if a person had a change to their skin integrity, the provider had made a referral to a health professional for support and guidance.

Partners has no specific feedback on this area.

The provider had a system and process for staff to keep clear summary documentation on people’s holistic needs. Care plans were reflective of peoples care needs and could be shared with other professionals if appropriate. Where people required external health and social care support, documentation showed that suitable referrals had been made. For example, a person required external health care support with skin integrity and a district nursing team visited to support with the health care need.

People told us they felt safe from abuse. One person said “I always feel safe. My bed is bigger than I expected, we all have double size bed. So, I do not worry about falling out.” People told us that there were no unlawful restrictions imposed on them. They were free to complete their own routines and live their lives as they wished. Some people would be at risk if they did not have continuous supervision and control. Where this was the case, we saw staff had applied the suitable Deprivation of Liberty Safeguards. These safeguards ensure people who cannot consent to their care arrangements in a care home or hospital are protected if those arrangements deprive them of their liberty.

Staff understood how to respond to allegations of abuse. Staff told us that they had no concerns, but if they did, they were confident the management team would act appropriately. Staff were confident in using whistleblowing processes if they felt concerns were not being responded to. The care manager understood how to respond to allegations of abuse. They were able to explain the process of how to investigate and keep people safe. Staff knew where to find the safeguarding policy. They were aware of the policy guidance and knew how to follow it to keep people safe from potential abuse.

We saw people and staff have positive relationships. There was an open culture of communication, and we saw no evidence that people were at risk or fearful of the staff team.

If an allegation of abuse, harm, risk, or neglect was made, there were appropriate policies in place to guide the staff team. Records showed that incidents were quickly investigated and referred to the local authority safeguarding team if needed.

People told us that they were able to communicate their needs to receive the right type of support. One person said, “I would give them 110 out of a hundred for everything. I am going home from here and they have restored my confidence enough for me to pick my life up.” People told us that staff understood their needs well and offered support to keep them safe.

Staff told us they had care plans in place that provided them with guidance and information on how to manage people’s risks. If staff were unsure, they would speak to the management team.

We saw people were supported safely. One person could become distressed. We saw staff were quick to respond to this person and offer support that reduced their agitation. This meant the person was kept safe as their distress did not escalate.

People’s needs were clearly documented in their care plans which meant staff had clear guidance on a person’s mental, physical, and social needs. Staff knew how to support people to manage risk. For example, one person required support when they became distressed. Staff knew how to respond to deescalate the person’s distress. Where incidents had occurred, staff and people were provided with the opportunity to review what had happened and ensure measures were put in place to prevent re-occurrence. Staff kept clear records on how they had supported people and at what time. This allows changes in a person’s needs to be identified and improvements made to their planned care. People’s communication needs were clearly recorded. This allowed staff to understand people’s needs/wishes and support them to stay safe.

People felt the environment was managed safely. People explained that their bedrooms felt safe to them. People told us that the call bells in their bedrooms were always working and accessible. This meant they could request staff support if needed.

Staff knew how to monitor the safety of the environment, and where to report any maintenance concerns too. Staff were confident that the building was well maintained to keep people safe. The management team described a clear process for monitoring the safety of the environment. For example, the management team documented their regular checks around the building and explained how they passed concerns to the maintenance team to resolve repairs. We saw that any areas they had picked up had been resolved to keep people safe. Staff knew how to respond in the event of an emergency evacuation. For example, if a fire alarm sounded, staff could explain how people would be supported to move into a safe space.

Some people at the care home used equipment such as walking frames or hoists. We saw these pieces of equipment were well maintained and stored appropriately. The home was safe in the event of a fire. Corridors were clear of any blockages, allowing people to follow easy to read escape routes. Staff had access to fire-fighting equipment. Windows were unable to be opened wide. This safety feature prevents people from falling or climbing out and is in line with guidance from the Health and Safety Executive.

The environment was kept safe by regular checks and maintenance. We saw there had been regular checks to ensure the home was safe in the event of a fire. For example, by checking the alarm systems. Systems were in place to ensure the water quality was maintained to reduce the risk of water bourne bacteria such as legionella.

People told us there were enough staff, and any needs were responded to quickly. One person said, “They [staff] always seem to appear straight away [when pressing the call bell]. I don’t know how they do it.” People told us staff were well trained and knew how to meet their needs. One person said, “They have encouraged my independence, but this has been easier knowing they are here to help.”

We have received mixed feedback regarding safe staffing. Staff told us people received support when they wanted but this meant staff had to rush and work at speed to meet everyone’s needs. Since our onsite assessment we have continued to receive concerns regarding, staff levels on shift. Staff told us they had regular opportunities to meet their manager on a one-to-one basis for supervision. These meetings gave them the opportunity to feedback about their experiences and request further guidance/training if needed. Not all staff had received suitable training to do their role. For example, only 50% of the staff team had completed fall awareness training and 47% of staff had completed choking training. This meant not all staff had the right skills and knowledge to provide safe care. The provider took immediate action and completed an investigation. After the inspection the provider told us training compliance had increased to training 61% for choking training , and falls awareness was at 75%. The provider also told us their overall training compliance was 70% and the percentages of training completed was impacted as they have recruited 8 new staff who are in their induction period.

During busier times, we observed that there was insufficient staffing to respond to people who wanted care and support. For example, during breakfast time, one staff member was supervising the lounge/dining area while two staff went to support a person. During this time two incidents occurred where people required staff support. One person wanted to move from where they were sitting but needed staff support due to being unsteady on their feet and one person required staff support as they had become distressed. The staff member told both people to sit back on the sofa as they could not provide them with the support they needed. The operations manager told us they would take action and during busier times such breakfast, they would use their lunch time strategy whereby all staff stopped their roles to provide support in the dining area. We saw staff were suitably trained to complete their roles. Staff used their training to respond effectively to people’s needs.

There were clear processes to ensure there were enough staff. The provider had used a calculation tool to assess how many staff were needed to meet people’s needs. The management team told us their policy was to have 2 more staff than the tool indicated, to ensure people received quality care. The rota’s suggested these staffing levels had then been arranged according to this calculation. Once staff were trained, there were clear ongoing processes to assess their competency. If needed, further support and training was then given to improve staff skills. If staff were not providing the expected level of care, there were clear processes to monitor and improve their performance. Safe recruitment processes were followed. For example, previous employers were contacted to give references on the staff member. Staff had also had regular Disclosure and Barring Service (DBS) checks. These check the police database for convictions or warnings that may impact the staff members safety to work with people.

People told us that the home was always kept clean.

Staff knew what personal protective equipment they should wear and when. Staff knew how to put on and remove this equipment, in a safe way. This protected people from the spread of infection. Staff had received food hygiene training. They were able to explain what actions they had taken to reduce the risk of food bourne infections.

The home was clean and hygienic. We saw that staff had access to personal protective equipment, such as gloves throughout the home. This allowed them to support people in a hygienic way. We saw any dirt or spillages in the home were quickly resolved. The home was safe in the event of a fire. Corridors were clear of any blockages, allowing people to follow escape routes. Staff had access to firefighting equipment throughout the home and fire alarms were throughout the building. We saw the kitchen was managed in a hygienic way to ensure people did not get food bourne infections. The most recent check from the food standards agency had rated the service 5 stars on the 23 May 2023.

There were clear processes and policies, to ensure the environment was kept clean and hygienic. This protected people from the spread of infection. If an infection outbreak occurred (for example diarrhoea and vomiting), there were clear processes in place to reduce the risk of this spreading to other people at the service. Staff had received training in infection control, how to put on protective equipment and how to keep people safe in the event of an infection outbreak.

People told us that staff gave their medicine at regular times, and as their prescription stated. People told us that they had ‘as needed’ medicines like paracetamol for occasional pain relief. They explained that staff supported them to take these ‘as needed’ medicines in line with their changing symptoms.

Staff were able to explain how they supported people to take their medicines safely. Staff knew who to report medicine concerns too. For example, if they felt a person’s medicine was no longer effective, they understood where to document this, and which health professionals to contact.

Medicines were not always stored securely. We found topical medicines and pain relief tablets in people’s bedrooms that could be easily accessed by people who could come to harm. The management team took immediate action during our visit to store medicines securely. However, when we went to check, we did continue to find medication still not stored securely. Staff kept clear records of when they had given prescribed medicines. We saw medicines were given as prescribed. Staff did regular checks of the amount of medicine in stock. This ensured that suitable stock levels were always in place, and more medicine could be ordered from the pharmacist as needed. Some people required ‘as needed’ medicine and staff had clear written guidance on how this should be administered. For example, one person required an inhaler if they became breathless. Staff had clear guidance on what symptoms the person would show, how much dosage should be offered and how quick the inhaler would have an effect on the person’s breathlessness. Staff had received training on how to administer medicines safely. The management team had regularly assessed the staff’s competency to ensure they were following best practice. Some people at the service were prescribed controlled drugs. These are subject to enhanced restrictions due to the addictive nature of these medicines. We saw staff had followed national legal requirements by storing these medicines in an extra secure place.