Kilmar 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

The service was safe and people were well cared for. Staff and leaders understood their roles in ensuring people were protected from abuse and discrimination. The service was well staffed, and staff had the skills and experience necessary to meet and understand people's individual support needs. The service engaged positively with health system partners and acted upon advice provided. Risks had been identified and appropriately mitigated. Medications were managed safely and given as prescribed. Accidents and incidents had been documented and investigated. Necessary environment safety checks had been completed and the service was clean and well maintained.

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 and their relatives were confident support staff understood their needs and were acting to ensure people’s safety. Comments received included, “The staff are good, I can’t see any fault with them”, “They all muck in together, [the staff] are all trying to make people’s lives as good as possible” and “They are looking after me.”

Staff were confident reporting and discussing details of incidents or change in people’s care needs with their leaders. This ensured opportunities for learning and improvement were identified promptly. Where leaders had identified issues with individual staff member’s performance disciplinary procedures had been appropriately followed.

The provider had effective systems to ensure incidents or accidents were documented and investigated. Daily records were also reviewed regularly by senior leaders to identify any changes in people’s support needs. Records showed timely and appropriate referrals for external advice had been made and any guidance provided acted upon.

People were welcomed and made to feel comfortable quickly when they first moved in. Relatives were complimentary of how smoothly transitions had been and told us, “[My relative] has been here a month now and I am happy. I think we picked a good one, I think they meet his needs. I can’t complain about anything.”

Staff and managers worked collaboratively with health partners to ensure people’s care needs were recognised and understood during any transitions between care services.

Professionals were complimentary of the service’s communication and told us, “The staff are friendly” and “They know how to get hold of us.”

There were systems in place to assess and identify people’s care needs before they moved into the service. Assessments were normally completed by the head of care, where possible in person, to ensure that the service was able to meet both people’s needs and expectations. When people moved out of the service or were admitted to hospital there were procedures to ensure accurate information about people’s current needs was shared.

People were relaxed and comfortable in the service and enjoyed spending time with their staff. People said, “[The staff] are there when I need them”, “It’s really very good here” and "I feel so lucky to be here." Relatives told us, “[My relative] is happy there because she has company and is well looked after” and “In general [My relative] trusts that they are looking after [them].”

Managers and staff had a good understanding of local safeguarding procedures and information about how to make safeguarding referrals was readily available. Staff were confident that any safety concerns they reported would be dealt with and told us, “I feel like I can tell [managers] if I have any concerns.”

People were relaxed and comfortable in the service. They requested support from staff without hesitation and received prompt and appropriate responses.

Records showed the staff team had made appropriate safeguarding referrals to the local authority when concerned about the safety of specific individuals. These concern’s had been investigated and steps taken to protect people from further risk of abuse. The service had processes available to access people’s capacity in relation to specific decisions in accordance with the requirements of the Mental Capacity Act (MCA). People were able to exercise control over how their care and support was provided and staff respected people’s choices. The service’s policy was not to restrict people’s ability to access the community and when this became necessary to ensure individual’s safety, notice was normally served as the service was unable to meet the needs of people living with advanced dementia. This meant the service did not routinely make Deprivation of Liberty Safeguards (DoLS) applications.

People told us, “I feel safe when they are lifting me” and “They look after me very well, no complaints whatsoever.” A relative said, “[My relative] always has a bell with them to call staff if needed and they are attentive in getting [my relative] walking around.”

All staff understood the support people required when eating to manage choking risks and catering staff were able to produce meals to modified textures when approved and required.

Staff supported people to safely mobilise around the service and any necessary equipment was used appropriately. Staff recognised the importance of supporting people to manage risks to their continence and independence. They responded promptly to assist people to the bathroom when requested.

Care records included clear guidance for staff on actions they needed to take to protect individuals from identified risks. Care plans included guidance on the use of pressure relieving equipment to manage risks to skin integrity. Staff completed regular checks of equipment to ensure it was working correctly and items were replaced promptly when faults were identified. Where health professionals had provided guidance or advice on the management of a specific risk this information was included in the person’s care plan and acted upon. Appropriate emergency evacuation plans had been developed and equipment provided to aid with the evacuation of less mobile individuals. Firefighting and detection equipment had been regularly serviced and tested.

People were comfortable in the service which was well furnished.

Staff understood emergency evacuation procedures and fire safety checks had been completed.

The service and its equipment was clean and well maintained.

The service was well maintained throughout and people’s bedrooms had been personalised. All necessary routine maintenance and safety checks had been completed by appropriately skilled contractors. Maintenance records showed prompt repairs had been completed when required.

People spoke positively of their care staff who they described as kind and caring. People’s comments included, “They are looking after me very well”, “The staff are good, I can’t see any faults with them” and “[The staff] are very friendly. Do everything they can to help. If I press the button and they come quickly.” Relatives were also complementary of the attentive staff team and told us, “The staff are so friendly and helpful, you can't ask for too much.”

Staff were confident they had the skills necessary to meet people's needs and were able to respond promptly when assistance was required. They told us, “There is never less than 2 staff on”, “We have enough staff” and “We have 2 carers on each shift.” One recently recruited staff member told us, “I did the induction, then was shadowing 2 shifts.” Managers told us, “Everyone has done or is doing the care certificate.” Records showed new staff had been supported to complete this training, which was designed to give staff new to the care sector, an understanding of current best practice.

On the day of our assessment we found that planned staffing level had been provided. The services rotas were well organised and demonstrated planned staffing levels had been routinely achieved.

Staff were recruited safely, all necessary pre-employment checks had been completed to ensure staff were suitable for employment in the care sector. Staff received regular supervision and team meetings provided opportunities for staff and managers to share ideas and learning. Where staff performance issues were identified necessary disciplinary action had been taken. The service’s training provider had recently stopped trading and as a result some staff had not completed training updates as planned. A new training provider had been engaged and training was scheduled to ensure staff skills were refreshed and updated.

People and visiting relatives had no concerns in relation to infection control practices and told us, “It is always clean and tidy”, "They clean every day and change bedding regularly” and “always nice and tidy.”

Staff had a good understanding of infection control practices and worked together to ensure these risks were managed.

The service was clean and stocks of Personal Protective Equipment (PPE) were available for use when required. The lounge was cleaned at lunchtime, while people were eating in the dining room, to limit the disturbance caused by cleaning tasks.

All areas of the service were cleaned regularly. Cleaning schedules and procedures were available detailing how infection control risks should be managed and mitigated. The service employed 2 domestic staff, one of whom was normally on shift every day.

People received their medication as prescribed and controlled how and when, ‘As required’ medications were used. People’s comments included, “I get my medicine when I should. They are pretty well on time.”

Staff understood the provider's systems for managing medication and told us their competency with medications had been assessed.

Medication Administration Record (MAR) had been accurately completed and demonstrated people had received their medicines as required. Medications were stored appropriately and securely when not in use and necessary environmental monitoring checks had been completed.