13/02/2020
During a routine inspection
We rated Kirkwood Road as Requires Improvement because:
•Staff did not always update risk assessments for each client. This meant that the service did not put a risk management plan in place to mitigate the risk or put in safeguards.
•Staff did not always contact police when a resident was deemed missing. Client records did not identify clients who were most at risk so that staff knew when to communicate with the police about high risk and vulnerable clients.
•Medicines’ audits were not effective in identifying errors or poor practice.
•Staff did not develop care plans and recovery plans that included the accessible information needs of clients with a disability or sensory loss, which meant there was no information for care staff or others on their communication needs or how they should be met.
•There was little evidence of how staff were planning for clients’ discharges. This was similar to the last inspection.
•The registered nurse in the service had not received clinical supervision from a registered nurse in the last 12 months prior to inspection.
•The governance overall was not robust enough to provide sufficient oversight of service performance, quality and safety. Systems and processes in place had not been effective in identifying problems with quality and safety in respect of medicines management, risk assessments, identification of clients’ holistic needs and expired items in the first aid box.
•The provider should ensure that staff plan appropriately for the discharge of all people who use the service.
However:
•The service had enough staff, who knew the clients and received appropriate training to keep clients safe from avoidable harm. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
•Staff treated clients with compassion and kindness, respected their privacy and dignity, and understood their individual needs. They actively involved clients and families and carers in care decisions.
•All clinical premises where clients received care were safe, visibly clean, well equipped, well furnished, well maintained and fit for purpose.
•Staff understood how to protect clients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
•The service treated concerns and complaints seriously, investigated them, learned lessons from the results, and shared these with all staff. The service gave clients, families and their carers information on how to make a complaint.
•Staff felt respected, supported and valued. They reported that the provider promoted equality and diversity in its day-to-day work and in providing opportunities for career progression. They felt able to raise concerns without fear of retribution