Kavanagh Place

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 remained good. This meant people were safe and protected from avoidable harm.

This service scored 72 (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. The management team listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. There was a system in place to manage and review accidents and incidents and these were discussed during staff meetings and daily huddles. Appropriate action was taken following incidents to reduce the risk of harm, any lessons learnt were discussed and shared with the staff team.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed and/or monitored. They made sure there was continuity of care, including when people moved between different services. We received positive feedback from health professionals about how the provider shared information and supported people moving between different care settings. One healthcare professional told us, “Over the last 18 months, [partnership working] has been fantastic. The management team are great. The [care staff] are nice, the care home is well led, the home is settled, I have no concerns.” There were detailed preadmission assessments in place and hospital passports had been completed for each person. Hospital passports provide key information about a person's care needs and care preferences in the event of a hospital admission. This was particularly important when the person was dependent upon others to communicate their care needs.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve it. 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 with the local authority and CQC. Staff received training and demonstrated a good understanding of what to do to make sure people were protected from harm or abuse. The management team had ensured authorisations to deprive people of their liberty had been sought when people were unable to consent to living at Kavanagh Place. Any conditions imposed by an authorised Deprivation of Liberty and Safeguards (DoLS) was known and reflected in care plans. We received positive feedback about the approach of the provider to dealing with allegations of abuse. A healthcare professional stated, “They safeguard things and are really open.”

The provider worked with people to understand and manage risks. Staff provided care to meet people’s needs which was safe, supportive, and enabled people to do the things that mattered to them. People had individual assessments of risk associated with their care and support. Risks were reviewed when people’s needs changed. These included, but were not limited to, risk of falls, diet, and nutrition. Staff were aware of these assessments and knew how to keep people safe. Family members felt their loved one was safe and secure living at the home. One relative told us, “I feel [Name] is safe. Because of their 1-1, staff are with them all the time.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care and equipment was serviced on a regular basis. Information and equipment were in place to support people to safely evacuate the home, if needed, which reflected their moving and handling and mobility needs. There was appropriate signage for people to orientate around the home, particularly those living with dementia. Some aspects of the environment used by staff were not sufficient. For example, works stations and medication facilities were very cramped which made it difficult for staff to work without distractions. We raised this and the registered manager explained plans were already in place to address this.

The provider 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. Staff were recruited safely. There was some use of agency workers. When possible, agency workers were pre- booked for consistency and received an appropriate induction. We observed sufficient staff on duty to meet people's needs. This was confirmed by people who lived at Kavanagh Place. One person told us, “There are enough staff on duty.” Staff received appropriate training to support people. This included training when supporting people with a learning disability or autistic people and training around individual medical conditions, for example, Huntington’s disease.

The provider assessed and managed the risk of infection. Any infection detected was controlled to avoid the risk of it spreading and the provider shared concerns with appropriate agencies promptly. We observed the home was clean, tidy, and personal protective equipment (PPE) was available for staff to use. People were supported by staff who had received training in infection prevention and control and knew how best to support them in a safe way.  A family member told us, “[Name’s] room is always clean. Their bed is changed regularly.”

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning how they took their medicines, including when changes happened. However, some improvements were needed around the recording of people's medicines. For example, records were not always fully completed to demonstrate medication applied via a patch to the skin was routinely applied to a new area, in line with best practice guidelines. A small number of medicines records were duplicated on the electronic medication system and one person's records had not been updated following a change from a medicine being prescribed on an ‘as required’ basis to a regular prescribed dose. Prompt action was taken in response to our medicine queries, and we were assured people had accurately received their medicines as prescribed. Some people had several prescribed creams, and some did not contain a date it was opened, nor was it always clear if the cream was still needed. We discussed this with nursing staff and a visiting professional who told us the management team had recently reached out for support in reviewing prescribed creams in the home. They were awaiting a change in some people’s prescriptions, so creams not needed were disposed of safely.