Kingdom 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

People were not consistently protected from potential harm. Whist we had not identified anyone had came to harm, we found that risks were not always identified or well managed. Medications were dispensed as prescribed, yet some practices in their administration were unsafe. The provider did not ensure risk assessment were detailed and suitable to people needs. The provider did not offer ensure adequate training and appraisal for staff. The provider did analyse accidents and incidents, which led to learning from these events. The service was clean and hygienic, and the staff were knowledgeable about safeguarding and the procedures for reporting abuse.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People reported that the staff listened to them and acknowledged their right to take risks. The team assisted one person in understanding and managing the risks associated with excessive fluid intake. People told us staff respected their decisions and encouraged their autonomy.

Staff and leaders were aware of how to recognise, respond and report risks, this resulted in lessons learned. One staff member said," I will identify and evaluate risks and select appropriate methods to manage the risks and monitor outcomes to make appropriate adjustments in methods.” We found some risks had been overlooked and were not effectively managed or overseen.

The provider implemented robust systems to document and report accidents and incidents, analysing any emerging themes and trends. The providers overarching quality and safety team identified serious incidents requiring closer examination and managed them at the provider level, offering necessary team support. Staff practices were guided by established policies and procedures. Supervisions and team meetings offered additional opportunities for learning.

People were at risk of receiving inconsistent care and support due to the lack of suitable and sufficient assessment of their health care and wellbeing needs. We found a health need had been overlooked meaning one person had not received professional oversight or advice for their condition for a considerable amount of time, no harm had been caused but the potential of harm had not been recognised. The provider took prompt action once we made them aware.

Staff familiar with individuals were able to support and respond to their needs effectively. However, the inconsistency in guidelines allowed for the possibility of inconsistent care quality.

Professionals were contacted concerning individuals' health needs, and new referrals were made to various professions for input. However, feedback from professionals and records indicated that the care related to health needs was inconsistent, leaving individuals at risk of receiving unsafe care.

Health records were not always up to date. Records relating to health needs were not always completed or promptly followed up where advise had been given. This meant immediate action regarding health needs was not effectively communicated to all staff to ensure consistency of care. For example, records relating to food and fluid, and weight had not been fully completed which left people at risk of not receiving adequate nutrition and hydration.

We observed people comfortable with staff support and said they were safe living at Kingdom House. People and relatives told us their loved ones were safe. One relative said, "Yes, I’d know if there were any concerns with my relative because their attitude would change." Although people responded positively and did not raise any concerns in respect of safeguarding we were not assured they were fully protected as records of safeguarding alerts and outcomes were not maintained.

Staff were knowledgeable about recognizing, responding to, and reporting abuse. They had undergone training in safeguarding and were familiar with the provider's policies and procedures on safeguarding. One staff member stated, "Should I notice any abuse, I will report it to the team leader. If no action is taken, I will escalate the matter to the manager, and if there is still no response, I will report it to the authorities."

During the inspection we saw when people were receiving assistance from staff they appeared at ease and content, as evidenced by their body language and expressions. After the inspection, we made a safeguarding alert to the local authority because the provider failed to adequately protect an individual's health needs. The provider responded promptly upon notification and took steps to safeguard the person.

Systems and processes were established to protect individuals from harm or abuse. The provider maintained a current safeguarding policy consistent with the latest legislation, and concerns were communicated to the appropriate agencies. However, records of safeguarding alerts were not maintained, and information about previous safeguarding issues was lacking in information to show an outcome.

Risk assessments were conducted for certain identified risks, outlining measures to mitigate them. However, not all risks were recognised, and staff did not always adhere to the risk assessment guidance, leading to potential exposure to risks. For instance, thickeners for individuals with swallowing difficulties were accessible, posing a choking risk. Checks of hot water outlets were not consistently taken, and risk assessments identified people were at risk from hot water. Additionally, one individual relied on equipment for skin integrity, but regular equipment checks were not followed, and we found the equipment was not properly to be effective. However, there was no evidence of harm to individuals.

Staff and leaders understood how to support people to minimise possible risks but hadn’t consistently practiced this, as previously noted. Staff confirmed risk assessments were in place and they could seek further guidance if needed.

Observations indicated that staff supported individuals according to their risk assessments and were well-versed in their needs. However, the inconsistency in records led to a risk of inconsistent care from staff members who were not familiar with the individuals.

The processes to monitor how risks were managed had not been effective in identifying and addressing issues we had observations during the assessment. Care plans detailing how to support people if they were distressed were not always consistent. This meant staff lacked clear guidance to ensure they consistent and proactive in their support of people. This was fed back to the provider. Risk assessments were in place for identified risks, which were reviewed and updated when there was a change in the person’s needs. Policies and procedures were available to support staff in the event of an emergency within the service.

People and their relatives and representatives said the environment was suitable to their needs. However, we did identify that there were gaps in environmental and equipment safety checks which could impact peoples safety.

Safety checks were being conducted, and the staff could explain the significance of these procedures. The interim manager had begun to introduce additional safety measures and to verify their consistent completion.

During the building tour, the environment was deemed safe. However, it was noted that some essential safety checks were not carried out. For instance, the risk assessment for safe bathing and hot surfaces required monthly thermometer calibration and water temperature logs, yet there was no proof of calibration, and the water temperatures were recorded inconsistently. Additionally, safety checks on medical equipment, which ensure the equipment's effective operation, were not conducted. One piece of equipment was found to need parts replaced, which the provider had not considered. The provider acted promptly once made aware.

The provider established policies and procedures to direct staff in maintaining a safe environment, and certain safety elements were upheld. The interim manager revised the checks for fire, legionella, electrical, and gas safety; however, these checks had not been consistently executed in the past. Furthermore, there was a failure to guarantee the completion of all safety checks, leading to ineffective quality monitoring.

People’s relatives and representatives gave positive feedback about the staff team and noted good working relationships with people who used the service. However, a lack of staff appraisals and training in the use of equipment meant that safe and effective care was not always in place.

Staff told us they didn’t always feel supported in their role. One staff member said, “I have had a recent supervision but never had an appraisal. Sometimes I feel supported, but never listened to.” Staff undertook training the provider considered mandatory, however did not feel confident that training had been sufficient for them to safely carry out their role. One staff member said, “I haven’t been trained in the use of equipment, just been shown by other staff.” Staff felt the staffing levels were safe but at times there had been a lack of team working meaning people were not meaningfully engaged. For example, a staff member said, "Kingdom house can be a great place to work certain staff seem to do a lot and others not as much and don’t give 100%. Some staff don’t interact with service users as they should."

We observed staffing levels were sufficient and in line with the support people required. People’s needs were met in a timely manner, and staff were able to spend time with people. Staff had not completed training in autism awareness, sleep apnoea, skin integrity or pressure awareness and moving and handling of loads to ensure they were suitably competent and skilled to support people in these areas. We reviewed policies and records relating to staff supervision and appraisals which identified that staff had not received annual appraisal of their work in line with the organisations policies and procedures.

Staff training was monitored to ensure the completion of essential training modules. Training specific to people's needs had not been provided to staff leading to staff members not being adequately trained to deliver safe support in vital areas such as equality and diversity, skin integrity, nutrition, and hydration. Records showed staff had not received an appraisal of their work in line with the providers policy. The recruitment procedures were robust, guaranteeing that individuals hired were well-suited for their respective roles. Additionally, records confirmed that staffing levels were always maintained at a safe threshold.

People were protected from the risk and spread of infection. People and their relatives told us the home was clean, hygienic, tidy and well maintained.

Staff carried out routine cleaning of the home and informed us they followed cleaning schedules to ensure the home's cleanliness.

The home was maintained in a clean and hygienic condition. Any areas requiring repair or replacement were attended to, enhancing the home's aesthetic appeal. We observed good infection control procedures being carried out by staff.

The provider had a policy and procedure in place for infection control. infection prevention and control audits took place regularly.

People and relatives did not share any concerns about the management of medicines. However, our findings during our site visit showed we could not be confident that people were being supported appropriately with medicines.

Staff were aware of their roles and responsibilities regarding the administration of medicines. Staff involved in the handling of medicines had received training about medicines. Staff were assessed as competent to support people with their medicines. However, the systems in place to check staff handled medicines safely required improvement.

The provider implemented policies for the safe handling of medicines, yet these policies did not encompass all aspects of medication processes. For instance, the method of documenting on the Medication Administration Record (MAR) when a medicine was not required lacked consistency. The service had safe systems for appropriate and safe handling of medicines. However, some documentation in the administration of medicines was not in place. For example, records for the use of emollient creams and lotions were incomplete. The absence of usage instructions for the thickening powder stored in the cupboard posed a risk to those who had access to it. Action was taken by the provider to reduce this risk once they were aware. Medicine audits were completed regularly but had not highlighted the above issues.