Kite Hill 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 requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to safe care and treatment and staffing.

This service scored 44 (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 have a clear system in place to investigate and learn from incidents. Management told us that accidents and incidents were reviewed on an individual basis, however there was no evidence to demonstrate that this included analysing incidents collectively and identifying trends, themes or patterns across the service.

The last fall’s audit was completed in June 2023 and the provider acknowledged these had not been completed since. This limited the providers ability to identify patterns, share learning, and proactively improve safety across the service. This meant opportunities to learn from incidents and prevent similar events from occurring were not consistently maximised.

There was a lack of evidence to demonstrate that lessons were learnt from incidents and when things went wrong. For example, there was no risk management plan in place following an incident where a person was found brushing their teeth with a topical cream. The management told us that following on from this incident that the person’s topical creams were removed and stored safely. However, during our inspection, we found two tubes of the same cream in the person's bedroom unlocked and easily accessible. This demonstrated that the action taken following the incident had not been effectively sustained and the ongoing risk had not been adequately managed.

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

The management told us that information packs were prepared and available when people transferred between services, for example, to hospital or another care setting. However, some records for people did not always provide sufficient information and guidance regarding all their health conditions and escalation processes. This meant staff and other healthcare professionals may not have had access to all the relevant information needed to ensure people received consistent care and support.

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. The provider did not always share concerns quickly and appropriately.

During the inspection, we identified concerns relating to safeguarding processes, risk management, and provider oversight. The provider had not established robust systems to identify, report, and respond to safeguarding concerns.

Records showed safeguarding referrals were not always made when required. For example, two people experienced limb entrapments, one whilst using bedrails and one who had bedrails down, but they remained attached to their bed. These were foreseeable incidents that placed people at risk of harm; however, records did not demonstrate that safeguarding procedures had been followed or that referrals had been considered. This meant the provider could not demonstrate that it was consistently working with external partners to drive improvements and achieve better outcomes for people.

At the time of the inspection the provider confirmed safeguarding audits were not in place. Following our inspection, management provided evidence that these have now been added to the audit schedule.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Individual safety risks were not comprehensively assessed, understood or monitored. Where action was taken to address risks, plans were not clear or co-ordinated. Care records often lacked detailed guidance to support staff in recognising risks, monitoring changes in people's health and responding appropriately to their needs. For example, care plans for people living with Parkinson's disease, diabetes and other long-term health conditions contained limited information about condition-specific risks and how staff should support them.

For example, where a person had a diagnosis of Parkinson’s disease and was prescribed time-sensitive medicines for symptom control, there was no risk assessment in place to support and guide staff around the importance of timely administration or the potential impact of missed doses. The care plan was very limited and there was no information about symptoms and progression of the condition. Management told us staff had not received training relating to Parkinson’s disease. The provider’s training matrix demonstrated that out of 25 care staff, no staff had received Parkinson’s Disease training.

The provider had not consistently managed pressure care risks. One person required repositioning every 4 hours; however, records showed that they were not always repositioned in line with their assessed needs. Records demonstrated several occasions where the person remained in the same position for more than 4 hours and at times up to 21 hours. This increased the risk of further skin damage and delaying wound healing.

The provider had not ensured risks associated with choking were appropriately, monitored and managed. One person’s records described how they had experienced a choking incident requiring staff intervention. However, there was no updated information in the person’s record to reflect this choking incident or additional measures required to reduce the risk of future incidents.

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

Although the provider carried out monthly monitoring of bedrails, these checks did not effectively identify whether protective covers were present, suitable and correctly fitted. Records demonstrated that protective bedrail covers were not routinely monitored. During the inspection, we observed several beds without protective covers and others fitted with covers that were either an incorrect length or unsuitable for the bedrail configuration. This increased the risk of further bed rail entrapment incidents and avoidable harm. The provider had not effectively identified or mitigated these risks through its monitoring processes.

Records did not demonstrate that fire drills included simulated evacuation scenarios or the use of evacuation equipment. This limited assurance that staff had practised the actions and equipment required to support people safely during an evacuation.

Despite these findings, the provider had implemented systems to maintain the safety of the premises and other equipment. Records demonstrated that regular servicing and safety checks of the building had been completed, including gas safety inspections, electrical installation testing and maintenance of fire safety systems. We also observed that moving and handling equipment had been routinely inspected and serviced to help ensure it remained safe and fit for purpose.

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, supervision and development. They did not always support staff to work together well to provide safe care that met people’s individual needs.

The provider had not ensured staff received training relevant to their roles or the needs of people using the service. The provider’s training records identified significant gaps in key areas, including catheter care, seizure management, falls prevention, oral health and end of life care. During the inspection management confirmed these shortfalls. This meant the provider could not demonstrate that staff had the skills and knowledge required to support people with specific health conditions safely and effectively. This increased the risk that people's individual needs may not be consistently met.

The provider did not have a robust system to assess people's dependency levels and determine staffing requirements. Staffing levels were based on an assumed dependency ratio of 25% of people having low needs and 75% of people having medium needs, rather than individual assessments that identified peoples actual level of care needs. Care records identified some people requiring high levels of support, complex healthcare needs and increased risks, including falls, pressure damage and diabetes management. However, these needs were not reflected within the provider's staffing methodology. This meant the provider could not demonstrate that staffing levels and skill mix were based on people's assessed needs. We observed staff interactions with people particularly who were cared for in their bedrooms to be limited and there was less time for staff to interact with them outside of personal care.

Staff we spoke with felt staffing could be improved, comments included, “My concerns are too long a time answering call bells,” “80% of time we are fully staffed but when someone from the kitchen goes off sick or other carers go sick we, as carers have to then cover it, plus continue to do the care work. I feel that we are short, we cannot give the best care to our residents” and “Think we have enough staff on shifts until people go sick.”

We found that the provider followed appropriate recruitment procedures and completed the necessary pre-employment checks to ensure staff were suitable to work in the service.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The provider had effective systems in place to assess and manage the risk of infection. We found infection prevention and control practices were effective. The home was very clean, well maintained and free from malodours.

Staff followed infection prevention and control practices. We observed staff using appropriate personal protective equipment (PPE), including gloves and aprons, when delivering care.

People and their relatives provided positive feedback about the cleanliness of the service.

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

We identified significant concerns in relation to medicine management. The provider failed to ensure people received their medicines as prescribed. People did not always get the medicines they needed, and we identified some people had been given medicines past there expiry date. We raised a safeguarding referral to the local authority.

One person living with Parkinson's disease did not always receive their time-critical medicines, or when they did, these were not always at the correct times. For example, between 11 May and 8 July 2026, staff recorded 45 missed doses due to the person being asleep and 8 missed doses due to refusal. Records did not demonstrate further attempts being made or escalation from the relevant professional. Furthermore, we identified a high proportion of late administrations. Approximately 70% was administered more than 30 minutes late, with some being administered over 3 hours late. This meant the person's symptoms were not being managed effectively, impacting their quality of life.

The provider did not manage medicine storage safely. We found expired medicines in stock and in use within medicine trolleys, including liquid medicines. For example, some people were being administered liquid medicine, however, the provider could not demonstrate the medicine had been opened within the manufacturer's recommended 2 month period as they did not contain opening labels. This meant the provider could not be assured the medicine remained safe and effective to use.

Staff also lacked clear guidance on when to administer ’when required’ (PRN) medicines as well as medicines with a variable dose. PRN protocols lacked personalised guidance and did not always reflect prescribing instructions accurately. For example, 1 person was prescribed pain medicine, with directions to take 1 or 2 tablets up to 4 times daily when required. However, the PRN protocol instructed staff to administer 2 tablets up to 4 times daily when required, which was not consistent with the prescriber's directions. The protocol did not provide guidance on when staff should administer 1 tablet rather than 2, how to assess the person's need for pain relief, how to monitor effectiveness, or what action to take if the medicine did not achieve the intended outcome. This increased the risk of inconsistent medicines administration and people not receiving treatment in line with their prescribed needs and preferences.