Kimwick 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

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 changed to Inadequate.

Inadequate: This meant people were not safe and were at risk of avoidable harm.

We identified 1 breach of the legal regulation in relation to the management of people’s individual risks, medicines, the premises and equipment being unsafe and infection prevention and control.

The provider did not always assess or mitigate risks to people’s health and safety. Care plans and risk assessments in place for people were not always detailed or accurate. The provider had not ensured the environment at the service was safe. There was no evidence that incidents and accidents were reflected upon to enable lessons to be learned. Staff were not always recruited safely; we identified gaps in recruitment records during this assessment.

This service scored 31 (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 did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

The provider did not effectively identify where lessons could be learned. People’s relatives told us they had ongoing concerns about the care provided to their family members and incidents and accidents were not always followed up appropriately.

People’s families had raised their concerns with senior staff but told us action had not been taken to address their concerns or improve the service. People were left at increased risk of significant harm.

The manager told us there had been no recent accidents or incidents involving people who lived in the service. However, one person’s relatives described two incidents that had placed the person at risk of harm. Insufficient action had been taken to ensure these incidents were escalated or recorded appropriately to enable reflection and learning to take place.

There was no oversight or log of accidents and incidents in place and accidents and incidents were not reviewed by senior staff. This meant there was a risk patterns and trends relating to people’s care needs and risks would not be identified.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services

People’s relatives told us the provider had not safely managed new people moving into the service. They described their previous concerns about 1 person who had moved into the service, the impact they had on the dynamic of the home and the effect their care needs had on other people living there.

Staff told us they were supported by the management team to ensure people were safely admitted to the home and had access to other services when needed. Staff told us they supported people to access the GP. However, evidence reviewed as part of this assessment demonstrated staff did not always support people to access other services promptly when needed. For example, concerns about one person’s health were not promptly escalated to the GP.

Services commissioning care on behalf of people living in the home told us they did not have confidence in the provider’s ability to work well with them for the benefit of people.

The provider’s systems and processes did not ensure they worked effectively with partners. They did not always share relevant information about people’s care needs with the bodies commissioning people’s care. This had resulted in commissioners having to make significant changes to one person’s support at short notice.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

We received limited feedback from people with regards to safeguarding. However, one person told us, if they had any concerns they could, “Talk to staff, I trust them.”

Staff told us they had received training in safeguarding adults and knew where the safeguarding policy was. They were able to explain how they would report any safeguarding concerns.

We observed staff treating people well. However, the safety concerns we identified during the inspection placed people at risk of harm. When we raised the concerns with the manager, they failed to take immediate action to mitigate all the risks, for example risks identified in relation to hot water and medicines management.

Incidents of suspected abuse were reported to the safeguarding authority appropriately. However, actions taken in response to allegations of abuse were not always effective. For example, a safeguarding referral was raised in response to concerns about support provided to people overnight. The actions taken by the provider to increase managerial oversight of staff on duty at night did not sufficiently mitigate potential risk.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not

share concerns quickly and appropriately.

The provider failed to manage and mitigate risks to people’s health, safety and well-being. People’s relatives did not have confidence in the management of risks to people’s health and wellbeing. One person’s relative was concerned about staff lack of action in response to incidents that posed a risk to their relative’s health and safety.

Management staff did not always recognise all risks involved in people’s care and the importance of assessing and addressing them to protect people, which put people at risk of harm. For example, they had not recognised the seriousness of concerns about risks to people raised by people’s relatives and commissioners of their support.

Staff told us they had access to people’s care plans, but these did not include clear and robust guidance on how to support people around their individual risks.

People were not always supported to mitigate known risks. The front door was left unlocked on the second day of our assessment site visit. Assessments completed for 1 person had identified the door should remain locked.

Risks to people were not adequately assessed. Care plans and risk assessments did not always contain current, detailed information about people’s needs in relation to medicines, eating and drinking, personal care, oral healthcare, risks from the environment and social activities.

This meant staff did not have access to the information they needed to support people in a safe way and mitigate risks to their safety and well-being.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care

We found concerns with the quality of the home environment that negatively affected people’s experience of living at the service. People’s relatives described their concerns with the safety and upkeep of the environment. They told us repairs had not been carried out in a timely manner despite them continually raising their concerns. Their concerns included the delays in appropriate action in response to a broken side gate, rubbish outside the front of the home, smoke alarms seen open with no batteries in place, light switches hanging off the wall and loose stair carpet.

Staff told us they reported maintenance concerns to the manager and until recently there had been delays in action being taken. One member of staff said, “We report to the owner or manager. Sometimes things take a long time, but recently a lot of stuff has been done.”

The provider acknowledged the findings of the assessment in relation to environmental safety. They had begun to implement the actions required to make improvements prior to the assessment. However, action had not been taken promptly enough and this had negatively impacted people’s experiences of living in the home.

During the inspection we saw several environmental concerns that posed a risk to people. Risks from hot water were not adequately managed. For example, water coming from taps in hand basins, showers and the bath, all of which were accessible to service users was hotter than the 44 degrees Celsius stipulated in the Health and Safety Executive guidance, ‘Managing the risk from hot water and surfaces in health and social care’.

People were at risk from hot surfaces. The majority of radiators in the home had not been designed or covered to ensure they did not heat to a temperature above 43 degrees Celsius stipulated in the Health and Safety Executive guidance, ‘Managing the risk from hot water and surfaces in health and social care’. During the onsite inspection these radiators felt hot to touch. No risk assessments were in place to identify and mitigate the risk this may pose to service users.

Appropriate fire safety measures were not in place, for example we saw a smoke detector had been covered; this would prevent it from working effectively in the event of a fire. We saw a fire door with a hole in it, this would have reduced its effectiveness in preventing the spread of fire and smoke.

Systems to ensure the safety of the premises and quality of service delivery were not implemented or accurately completed.

The provider had failed to adequately manage environmental risks. No environmental risk assessments were available during the assessment to identify hazards in the home, assess how they may cause harm and identify what action would be taken to minimise harm to people. Senior staff were unsure whether these had been undertaken. This placed people at risk of harm from the home environment.

The provider had failed to adequately manage fire risks. A fire risk assessment had been undertaken which identified several areas where fire safety measures required improvement. The attached action plan was blank, and no action plan had been created to ensure these requirements were addressed in a systematic, timely way.

Fire drills were not taking place frequently enough to ensure people and staff would know how to respond safely in the event of a fire. No fire drill was recorded as taking place since 22nd January 2024. The failure to safely manage fire risks placed people, staff and visitors at increased risk of harm from fire.

People were at risk from unsafe gas appliances as the gas safety check had not been completed within the required time frame. We discussed this with senior staff and a gas safety certificate was issued on 20th November 2024.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support,

We received limited feedback from people with regards to staffing levels in the home. Although some people’s relatives told us there appeared to be insufficient staff on duty at times to cover people’s allocated 1-1 staffing hours.

Staff told us there were enough staff on duty to enable them to meet people’s needs. However, staff were unsure how people’s 1-1 support was allocated and told us they decided this amongst themselves and sometimes shared these duties. There was a risk people would not receive their support as identified in their care plan and risk assessments.

During the onsite assessment visit we saw staff were available to meet people’s needs and we observed they attended to people’s needs promptly.

The process to manage the deployment of staff was ineffective. A staffing rota was in place, but it did not record which staff on duty were responsible for people’s 1-1 support. We could not be assured people received their 1-1 support as identified in their care plan. During the assessment a 1-1 rota was implemented.

Staff were not always recruited safely. We reviewed staff recruitment records and found gaps and inconsistencies in information that was required to ensure safe recruitment. For example, files reviewed did not contain an application form or record of interview.

There were ineffective systems and processes to ensure staff received suitable training. There was no training matrix in place at the time of the onsite assessment visit. A training matrix was provided later during the assessment; however, 3 staff members’ names were not recorded on the training matrix. In addition, mandatory training, including food hygiene and moving and handling objects was missing from the matrix. Following the assessment another updated matrix was provided that did contain the names of the missing staff and moving and handling training, however food hygiene training was still not recorded.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Although people did not raise any concerns about the cleanliness of the home, our inspection identified multiple environmental infection prevention and control concerns that put people at risk of ill health.

Although staff told us they received training in infection prevention and control, they did not work effectively to mitigate the risk of infection. For example, on the first day of inspection the inspector advised staff there was no hand towel in the downstairs toilet and no other means of drying hands after washing them after using the toilet. Staff said there was no hand towel available, and nothing was provided for drying hands for the whole of the first day of our site visit. Four days later, on the second day of the inspection there was a loose roll of hand towel available in the downstairs toilet. It did not fit the hand towel dispenser and had been placed on the windowsill. A piece had to be torn off using wet hands resulting in the remaining hand towel that would be used by other people being left wet.

A dirty mop was stored in a bucket in the downstairs toilet. The light pull cord was ingrained with dirt and had a frayed end. The pedal bin was broken, and the pedal did not work meaning the bin lid had to be touched with hands to open and close it. Senior staff said they were aware of the broken pedal bin, and this was replaced by day 2 of the inspection.

Extractor fans throughout the home were dirty with a build-up of dust and dirt, there was no plan in place for them to be cleaned.

The kitchen was not clean or sufficiently maintained, staff were not following safe practices to manage food hygiene risks. The walls in the kitchen were stained and ingrained with grease. The integrated cupboard containing the fridge freezer was chipped and very dirty at the bottom. Decanted food items in the fridge had not been labelled with a date of opening and there were out of date items in the fridge.

The provider had not implemented effective processes to protect people from the risk of infection.

A current Legionella risk assessment was not in place. The risk assessment in the Legionella section of the health and safety folder stated the next assessment was required by 24th August 2022, the manager confirmed no other assessment was available.

Measures to mitigate the risk of Legionella were not being completed, the manager confirmed regular cleaning and descaling of shower heads had not taken place.

Water temperature testing to mitigate the risk of Legionella was not being safely implemented. The hot water temperatures recorded for the months of July, August, September and October 2024 were below the safe temperature of 55 degrees Celsius identified by the Health and Safety Executive as the safe temperature for water distribution in care homes. The manager told us this was because staff were testing the water from outlets that were fitted with thermostatic mixer valves designed to keep the water at a lower temperature. There were no records of water testing available after 2nd October. People were at risk of illnesses that are associated with the risk of exposure to Legionella bacterium.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

People were unable to communicate with us about the support they received with their medicines. However, our observations identified unsafe practices.

We looked at Medication Administration Records (MARs) for 2 people. Staff had not recorded any of the prescribed medicines that had been brought into the home for the current cycle of medicines and there was no record of the stock of medicines held for any of the people who lived in the home. Staff were unable to explain when they had stopped recording the number of medicines prescribed for people or why they had stopped doing this. There was no way for staff to check the number of prescribed medicines in the home at any given time was correct. Staff could not effectively investigate potential medicines errors. In addition, there was no way for staff to monitor stock levels to ensure people’s medicines were ordered promptly.

When we carried out the second day of the onsite inspection the manager told us the medicines had still not been counted.

MAR charts were not fully completed as staff were not consistently or correctly counting the stock of medicines at the time of administration.

The service was using two different types of MAR chart and had failed to ensure staff used the correct code as directed by the MAR chart they were completing. For example, 2 different codes had been used when people were away from the home and their medicines were not administered by staff. Codes were used inconsistently and some codes used by staff were not present in the MAR chart key of codes to be used. The use of 2 different MAR charts was confusing for staff and increased the risk of medicines and recording errors.

Controlled drugs were not stored safely (a controlled drug is a drug that is regulated by the government for its manufacture, use, and possession). During the inspection we saw there were several items in the controlled drug cupboard that did not appear to be controlled drugs. These items included unprescribed homely remedies such as Paracetamol and stock of prescribed medicines that should have been stored in peoples’ individual medicine cabinets in their rooms. The provider failed to ensure staff followed safe practice and adhered to the medicines policy in place.