This short podcast is on behalf of the West Sussex Safeguarding Adults Board and is about an Organisational Learning Review, which looked into the involvement by agencies, in the lead up to the necessary closure of Kingswood Care Home in Worthing.
Firstly, I would like to tell you a little about Kingswood Care Home and the residents they supported. Kingswood was a Residential Care Home, which at the time of closure in February 2020, provided accommodation and support for 20 Residents who were both male and female. They had a range of care and support needs and, some were living with Dementia.
The closure of Kingswood occurred following the Ambulance Service attending in response to a 111 call about a Resident. When they arrived, it was found that the resident had died. The crew also, found that another resident had died unexpectedly and became so concerned about the care provided that they telephoned the police.
Further ambulance crews were called to Kingswood Home. They identified that several residents were mildly to moderately hypothermic and several showed signs of dehydration and neglect. There was also evident neglect of the environment.
Several agencies were then involved to co-ordinate an immediate response to ensure the safety and wellbeing of residents at Kingswood and, the Care Quality Commission began an inspection where it was identified that concerns were of a level that necessitated the cancellation of the Care Homes registration with CQC. This meant that the home had to close as it was too unsafe to provide adequate care.
The Review identified seven key findings about what was happening at the Care Home. These were:
- that concerns were raised; however, these did not prompt improvements
- that the provision of care was poor and there was a lack of responsiveness to residents’ care needs
- there was a lack of robust internal oversight
- there were concerns regarding inadequate staffing levels and, concerns with staff morale
- there was a lack of reporting of safeguarding and quality concerns
- that concerns were not always followed up and no patterns were identified and responded to and,
- that residents’ family members appear to have been unaware of concerns at the home.
The Review made recommendations to take forward the learning needed to improve the practice of agencies involved in working with the home and, to minimise the risk of similar situations reoccurring. The Board has summarised the recommendations under three key areas.
The first is partnership and multi-agency working, including with the private and voluntary sector, to ensure clear understanding of service requirements, safeguarding, quality and health and safety concerns.
Also, enabling the clarity of any actions required, when and by whom when there are persistent concerns about services; supporting homes where there are quality concerns to make the necessary improvements; working together to use different powers and responsibilities to improve quality and safeguarding in services and, being assertive with care providers about standards and expectations.
The second area is professional curiosity which is, in this case, considering not only the purpose of visits but also the care of other vulnerable adults, the environment, culture and practices. There is also, a need to develop strategies for overcoming a reluctance of care homes to engage due to a possible closed nature in homes and to recognise the limitations of overly optimistic approaches to service improvement.
And, finally the third area is safeguarding and quality including: identifying and sharing information on unusually low, or high reporting levels of accidents, incidents, quality issues and safeguarding concerns; supporting those who whistleblow or raise safeguarding concerns so that they do not face discrimination and disadvantage and, supporting family members’ understanding of quality and “what good looks like” in care homes and, supporting them to raise concerns when required.
The Board is committed to taking forward and seeking assurance on the learning as a result of this Review. We encourage you to take the time to consider how the circumstances of and the learning from this Review can improve and better inform your working practice.
To do this, we ask you to reflect on any areas of learning required, to support your practice to be current in order to improve the experience and outcomes of those we support.
Please visit the Board website to view: The accompanying learning briefing and full Review report; and specifically, in relation to this Review our: Professional Curiosity Learning Briefing, Safeguarding Thresholds Guidance, Information Sharing Guide and Protocol, Escalation Policy, and Operational Framework for Managing Provider Concerns.
On our website you’ll also find useful links to all our safeguarding policies and procedures, information for professionals, and other Reviews and podcasts.
We thank you for your time to listen to this podcast today and, we appreciate our colleagues moving forwards with us to ensure the learning from this Organisational Learning Review makes a difference for those who we are supporting.