Kirk 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

At this assessment we did not assess all quality statements within this key question. We found 5 breaches of regulation which related to need for consent, dignity and respect, safe care and treatment, premises and equipment and safeguarding people from abuse. People were subject to restrictive practices that were not regularly reviewed to ensure they were justified. There was no evidence the provider had taken steps to reduce some restrictive practices or evidence that people had been supported appropriately to ensure they had not suffered emotional or psychological harm. Staff understood their responsibility in relation to safeguarding people from abuse, however when some concerns had been raised there was no evidence that appropriate actions had been taken to keep people safe. Additionally, we received a large number of anonymous concerns from staff. Decisions made in people’s best interests were not regularly reviewed. Additionally, people were not always supported to share their views and have them accepted. Staff were recruited through robust processes. Staff had completed training in line with their role which was up to date. However, training was not always effective. There were areas in the environment that were not safe or clean. Food was not always handled or stored safely, additionally there were areas in the home that were poorly maintained and required deep cleaning. Medicines were not always stored or managed safely.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

A relative told us that staff visited their family member at home before they moved in to get to know them. We could see from reviewing documents that relatives had been involved with discussions around their family member before they started to use the service. However, people’s experience of their care once they had moved into the service did not always reflect the information given at assessment or stated in their care plans.

The registered manager told us how they worked with other professionals and services, so they had the correct information to ensure people experienced a safe and smooth transition between services. They gave us a recent example of a person who had required dental work where various professionals had been involved including a speech and language therapist to ensure a positive outcome for the person.

Feedback from partners was mostly positive. One professional told us there was significant information available which helped with reviewing people’s care and support needs. Additionally, a professional stated they felt the provider was open and transparent in their communication, however, another professional we spoke with told us they had concerns about the lack of engagement with them.

Professionals were contacted concerning individuals' health needs, and various referrals were made for their input. There was evidence a person had been supported safely to transition from the service to another provider. A staff member told us it was a smooth transition and a positive experience. The provider had not always identified and addressed times where care plans and guidance were not followed, after transitions had taken place.

Relatives we spoke with believed their family members were safe. One relative told us, “[Person] is in a safe environment, the gate is locked on the outside and they can walk and run. There are never any out of control situations.”

Staff were aware of their responsibility to safeguard people and what the procedures were in the event of any safeguarding concerns. They told us how they could raise concerns with the management team and knew how to raise concerns externally if required. Some staff we spoke with were unable to explain why some restrictive practices were in place. When asked, staff suggested reasons why they locked people’s bedroom cupboards or isolated the ensuite bathroom water supplies, however they did not always know the rationale for the restrictions. Decisions made in people’s best interests were not always reviewed. The registered manager told us for 1 of these decisions they had not had a full best interest meeting, but they continued to monitor, and it was discussed within general personal care.

The people we observed were supported by staff and appeared relaxed. We saw a person make a drink when they indicated they wanted one. Bedrooms required key coded access to them where there was another locked door creating an airlock system. Some of these bedrooms were open for people and some were closed at all times and would have required a staff member to open them if allowed. We did not observe anyone out in communal areas during our assessment whose bedrooms were locked.

Systems and processes were in place for staff to raise concerns, however we received a large number of anonymous concerns where staff told us they did not feel they could raise them with the provider without personal repercussions. Some people had strict protocols, for example, a person had a protocol for accessing communal areas. The protocols did not include information that would ensure staff understood the risk and when they should take certain actions. This meant protocols were open to interpretation when staff should offer redirection or more restrictive practice like removing them from communal areas or using physical restraint. There was no evidence protocols had been reviewed for their effectiveness. Decisions made in people’s best interests were not regularly reviewed. A restrictive practice that had been agreed as in a person’s best interest had not been reviewed for 4 years to ensure it was still a proportionate response to any assessed risk. We saw in a request to deprive someone of their liberty that an undignified and restrictive practice used daily had not been included in the application. The Deprivation of Liberty Safeguards (DoLS) procedure protects a person receiving care whose liberty has been limited by checking this is appropriate and in their best interests. Following our assessment the provider carried out another best interest meeting. Additionally, the provider had applied for another DoLS authorisation which did include the information relating to the restrictive practice. People were not always supported to share their views and have them accepted. A mental capacity assessment showed a person had given clear responses but then appeared confused when staff repeatedly asked the same questions. Consequently, the person was deemed to not have mental capacity and the decision was made in their best interests. Not all relevant people were included with best interest decisions including people’s relatives and funding authorities.

A relative told us that staff knew how to manage risks and will ‘back off’ and give the person space if they were distressed. Another relative told us, “I am confident they manage risks and I don’t need to be involved.”

Staff told us how they supported people to take positive risks. They explained that if a person wanted to do something assessed as high risk, they would enable them to participate if they could. Staff told us they judged risk continually when they were supporting people to know whether someone could safely take part in a particular activity, for example, if a person became unsettled or distressed before cooking. Staff told us people who were living in airlock environments were given as much communal access as possible and they were constantly trying to improve people’s tolerance to being in these areas. Despite staff feedback, we found through looking various care records staff were not following in practice what they told us as some people were spending large amounts of time in their bedrooms without the opportunity to take part in meaningful activities. Additionally, some people mostly took part in controlled or on-site activities like visiting the on-site gym or local walks. The provider told us people often refused activities; however, this had not been recorded in daily notes to show how people refused and what actions had been taken by staff to offer alternatives to encourage people to choose an activity they preferred.

We saw in a person’s care plan there was a risk of choking due to eating harmful produce and their risk assessment stated Control of Substances Hazardous to Health (COSHH) cupboards must be locked. However, we found the ground floor kitchen COSHH cupboard was unlocked. We saw some people making a drink in the kitchen with support from staff. Staff told us some people were on trips or returning from trips. Other people were not visible in the communal areas.

Risk assessments were in place, however, some risk assessments promoted restrictive and reactive practices without considering least restrictive methods first. Staff were more likely to have unfair bias towards people because of the environments they lived in, and the strict protocols created around their care and support. There was evidence of staff responding to people’s distress in reactive ways instead of using proactive and less restrictive strategies to prevent the incident occurring in the first place.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

There was mixed feedback with regards to staffing. Some relatives felt there were enough staff and believed there was a consistent staff team who supported their family member. One relative told us that staff moved around different services so there was a variety of staff who could support their family member however, another relative stated in a survey there were too many staff changes. A relative wrote in a provider survey that communication from staff had been affected by the high rate of staff turnaround. A relative told us that staff training was good and there were many opportunities for staff on a professional and personal basis.

Staff we spoke to felt there were enough staff to meet people’s needs. A staff member who worked at night told us they would radio over to another service which was located on the same site if they required support. However, the CQC had received a significant number of anonymous concerns regarding the impact to staff and people from staff shortages due to poor rota planning and staff being moved to support other services. These concerns were also echoed in staff exit interviews shared with us by the provider. Staff told us they worked well as a team and progression within the company was supported by the managers.

In communal areas we could see there were enough staff to support people so their needs were met. An expert by experience observed some people who lived in the air locked rooms with their own staff member. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Staff were recruited through robust processes. Staff also underwent a Disclosure and Barring Service check prior to starting work. This helped ensure the provider employed only staff suitable to work in this type of service. Staff had completed training in line with their role which was up to date. However, training was not always effective in ensuring staff knew how to assess risk and understand restrictive practice. Some staff were expected to carry out audits as part of their role, however findings from the most recent audits had not identified the risks we found during our assessment.

We saw in a family survey, a relative had raised concerns about the standard of cleanliness in their family member’s room. They stated that after sharing these concerns some improvements had been made but felt they needed to visit the service more often to monitor the situation. Another relative had mentioned in the provider’s survey, “On 2 occasions their room has been in a dreadful state when we have visited. We wonder how often they are left on their own to make such a mess.” People, particularly those with health conditions which made them more vulnerable to infection, were left by the registered manager at risk of harm from the potential for food poisoning from concerns we observed. Following the on-site assessment, the provider acknowledged the concerns and told us they had since taken action to address them.

We fed back to the manager who was supporting the on-site assessment the concerns we found in relation to the cleanliness of the environment. They showed us the manager’s health and safety audits that were completed weekly. It was evident from reviewing these audits that the concerns we found had not been identified by the staff member completing these audits.

There were areas in the environment that were not safe or clean. For example, some windows on the first floor had not been restricted so they could be fully opened, this meant there was a risk that people could potentially fall from height. We found food in 1 of the fridges had not been labelled to show when it had been opened and the first-floor kitchen had an ant infestation. The freezer in the first floor kitchen was so frozen over it was not possible to open the top 3 drawers. We saw frames of people’s specialist chairs were unclean with food debris left on the sides. Material on chairs and a specialist mat were torn and stained. There were areas in the home that had been poorly maintained. For example, sealants around the worktops and flooring were worn and there were areas in the kitchen that were coated in grease and debris. The laundry room had a very strong malodour. Additionally, the door to the laundry room was unlocked which meant chemicals were left accessible. The filter in the tumble dryer had a large excess of lint wrapped around it which posed a fire risk. Following our feedback the provider took swift action to ensure all windows were made safe and identified areas were cleaned.

The provider had systems and processes to complete environmental checks and health and safety audits. These had not been effective in identifying the concerns we found during our assessment. We saw audits were regularly scored by the staff members as the highest score even though there was evidence some concerns had been ongoing for a while.

Relatives told us instructions on how to give medicines were simply set out to enable them to give medicines safely when their family member visited them. Another relative told us, “I am informed of any changes. Staff have established a routine with [family member] and they have got a lot better at taking tablets.”

A staff member we spoke with who was competent to administer medicines was able to explain the procedure for ordering medicines which we were told was completed by the managers. Staff had limited knowledge on psychotropic medicines and Stopping over medication of people with a learning disability and autistic people (STOMP). A staff member trained to administer medicines told us that no one was prescribed psychotropic medicines and they did not know what STOMP was. We would expect staff who are competent to administer medicines to understand about psychotropic medicines which are medicines that can affect mood and behaviour and are often used to control people’s distress. We were aware that some people at Kirk House were prescribed psychotropic medicines. The registered manager told us medicine reviews were carried out every 6 months or annually depending on what medicines people were on. The registered manager told us a person was currently going through a reduction in medicines and they were able to collate information recorded by staff like perceived moods to monitor the person closely.

The systems and processes were not always effective in ensuring safe management of medicines. For example, a person’s medicine was crushed prior to administration without appropriate guidance from a pharmacist. Additionally, an ‘as and when’ (PRN) medicine protocol was found to be different to the dispensing label which could cause confusion to staff. Following our assessment, the provider requested signed documentation from the pharmacist around the crushing of medicine and also asked the GP to review the PRN medicine label. Guidance for the administration of medicines not administered orally, was not always being followed. Following our assessment the provider sought further advice and ensured medicine records were reviewed, however the care plan was not updated. The provider told us they were planning to review all people’s medicines who were administered using different methods. There were some concerns around the safety and storage of medicines. Medicine cabinets were found to be unclean, and waste was not in a tamper proof bin. This was not in line with current national guidance. Staff told us the thermometer for recording temperature of the medicines was not working. However, minimum and maximum temperatures were still recorded despite the new thermometer not having that functionality. Following feedback, the provider acknowledged the information could not have been accurately known and told us they had taken action.