Kailash Manor Care Home

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

During our assessment we found the service was safe. We observed safe practices, for example, when staff were supporting people using equipment. The home was clean and well maintained. People were protected from harm because the home had effective systems in place to manage any risks of harm. Medicines were administered safely. Staff were recruited using safe recruitment practices. However, when reviewing care plans we found some out of date diabetic plans. We reported this to the registered manager. Following our visit we have been assured these plans have been updated.

This service scored 78 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People felt confident that the provider had a clear process in place to learn from mistakes. When things went wrong in the service lessons learned were recorded and shared with team in 1:1 meetings and team meetings. This meant people could be assured their safety was a priority.

Staff and leaders told us they had an open and honest culture. Staff were encouraged to speak up and report any concerns or issues. The registered manager shared 2 examples of learning lessons when things went wrong.

The provider had a process in place for learning lessons when things went wrong. Clinical meeting minutes contained information about any lessons learned. Monitoring reports showed a breakdown of incidents. Each incident was reviewed and analysed for trends and patterns and the learning was shared in team meetings. This meant people’s health and well-being was monitored closely to address any changes as early as possible.

People told us they had good support from staff when attending appointments such as at the hospital. People’s records showed that information about hospital appointments was clear and concise. This meant when sharing people’s information with health care providers this was done in a way which assisted people to receive the best care and support.

Staff and leaders told us that it was important to ensure people could move between services and this should be done as smoothly as possible.

The local authority had completed several visits to the home to monitor the service's quality of care. They shared their reports with us. They stated that the home was meeting their expectations in terms of the quality of care being delivered. They did not have any concerns about the home. In addition the home received very positive feedback from other partners for example, one pharamist said, " The audits we have carried out for them [Kailash Manor] have always been outstanding and we have found that their medicines management is consistently very thorough. It is a pleasure to work with such a remarkable care home."

The provider had a process in place to ensure people had a safe journey when moving between services. There was a referral and admissions process in place. This helped ensure the provider could have the support of other health and social professionals, where this was required to meet people's needs When supporting people to move between services there was a clear communication strategy in place.

People experienced safe and effective care and support. People and relatives told us they were in safe hands. Staff interactions showed they knew people well.

Staff and leaders were able to explain different forms of abuse and how to report concerns.

During our visit we observed safe practices between staff and people. Relatives and visitors came and went throughout the day. Staff interacted with everyone in a calm and professional manner. Staff were patient and attentive. People were relaxed in the home throughout the day.

The provider had a clear process in place for safeguarding. Records reviewed showed concerns had been shared with the local authority and CQC when needed. Safeguarding logs showed actions and outcomes that were identified because of any safeguarding investigation.

People and relatives said they felt supported to understand and manage risks. People in the home were encouraged to take on roles like health and safety representative and work with the staff, leading in regular meetings. For example, one person who owned their own business was interested and had the skills and knowledge in health and safety, they would have a meeting with the residents first then join a meeting with the provider afterwards.

Staff and leaders had a good understanding of monitoring and managing risks of harm to people’s well-being. Staff and leaders explained how to keep people safe, for example, by checking equipment to be used in the home prior to using it.

We observed staff following good and safe practices in terms of mitigating any risks of harm to people.

The provider involved people in their care planning and reviews. People and relatives were able to have as much input as possible. A care needs assessment was carried out by the provider which included any identified risks of harm. Documents showed risks were monitored and managed well. This meant people could be assured that their health and safety was a priority.

The home was well maintained and adapted for people. People and relatives told us they had no concerns about the environment.

Staff and leaders told us the home was purpose built and had a good maintenance plan in place.

During our visit we walked around the home. We noted it was clean and tidy. People’s bedrooms were spacious and hazard free. All areas were well maintained.

The provider had a clear system in place to ensure the home was well maintained, clean and suitable to meet people's needs. Service records showed actions and completion dates for work carried out for example if a toilet seat was broken. Maintenance issues were logged and managed in a timely manner.

People and relatives told us they were happy with the care being provided. People were praiseworthy of how caring and supportive staff were.

Staff told us there was enough staff on duty to meet people's needs. If needs changed then staffing levels would be reviewed. Staff stated they were well trained and well supported in their role.

During our visit we observed that there were enough staff on duty to meet people’s needs. We saw that staff attended to people in a timely manner.

The provider had a clear process in place for recruiting staff. Background checks including criminal records checks were carried out for staff prior to starting in their role. This meant people could be assured that staff were fully vetted before taking up their job role. Staff received regular supervision and appraisals. This meant they had good support in their roles and could seek regular guidance when needed. Staff received regular training in a range of topics which enabled them to do their jobs more effectively.

People and relatives told us that the home was clean and staff used gloves and aprons.

Staff and leaders told us how to prevent the spread of infection, for example, by following good hand washing practices.

The home was clean, we observed staff using personal protective clothing (PPE) such as gloves and aprons throughout the day when supporting people. This meant people could be confident that the risks of infections were mitigated as much as possible.

There was a clear process in place to manage infections. The home had several hand washing facilities. Guidance and posters were in communal areas to remind people and staff about good infection, prevention and control practices. Health and safety audits were undertaken which included infection prevention and control. This meant any concerns could be picked up and addressed in a timely manner.

People told us their medicines were given safely. People and relatives did not have any concerns about medicines.

Staff told us that they were trained and assessed as competent to administer medicines and supported by senior staff. The home was supported by a dedicated pharmacist that advised with medicine related matters and projects. The service had systems to ensure staff knew about medicine incidents, safety alerts and learning lessons were shared with the team, so people received their medicines safely.

Stocks of prescribed medicines were managed appropriately. Medicines was administered at the times prescribed including time critical medicines. Care plans were detailed, and person centred to support staff with managing specific health needs, however diabetic care plans were not current and up to date, this meant staff could be following out of date information, which could lead to mistakes being made. This was immediately addressed by the provider. People were supported to receive their medicines in a way which gave them independence by self-medicating, when this was safe and appropriate for them.