Kemple View

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

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question outstanding. At this assessment the rating has changed to requires improvement.

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 regulation for not maintaining a safe and clean environment.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

We have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

• There were 10 serious incidents in the past 12 months. Incidents were investigated and learning taken from the incidents. Examples of lessons learnt included actions put in place to reduce the risk of physical assaults and the implementation of a new policy to monitor and manage patients who went absent without official leave. Procedures were in place to enable incidents to be discussed at a senior governance level and learning was shared with staff across the site through bulletins, emails and meetings.
• All staff knew what incidents to report and how to report them and staff reported all incidents that they should report.
• Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if, and when things went wrong. There had been 1 duty of candour report in the last 12 months.
• Staff received feedback from investigation of incidents, both internal and external to the service and met to discuss that feedback. Staff received bulletins which contained learning from incidents at other Priory Group services.
• There was evidence that changes had been made as a result of feedback, for example, following an incident review, managers had implemented a system where all staff familiarised themselves with the contents of the emergency grab bag on a regular basis to ensure all staff could recognise items within the bag that might be needed in an emergency.
• Staff were debriefed and received support after a serious incident.

We work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when people move between different services.

• The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met.
• Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge.
• Managers had regular meetings with commissioners to review patient’s care. We received feedback from 6 commissioners for the service. Commissioners felt staff worked well with them and other external stakeholders to manage patient safety and ensure continuity of care. They told us the service was responsive to any concerns raised.

We work with people to understand what being safe means to them, as well as with our partners on the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and we make sure we share concerns quickly and appropriately.

• Staff were trained in safeguarding, knew how to make a safeguarding alert, and did so when appropriate. Safeguarding training compliance was at 99% for levels 1 and 2 and 100% compliance for level 3. Kemple view had a social work team who supported staff with safeguarding training and cases. The hospital had a safeguarding Children and Adults policy which was in date and provided clear structure and direction for safeguarding matters.
• Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.
• Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies.
• Staff followed safe procedures for children visiting the service. The service had a family room that was separate from the wards and there were procedures in place to support visits from children.
• The service had an up to date, relevant policy providing guidance to staff around restraint and restrictive practices. Staff had received training in reducing restrictive practice and intervention breakaway training and were 100% compliant with this training. Each ward had a restrictive practice audit tool in place and managers reviewed restrictive practices every month. Most restrictive practices were individually considered and care planned.

We did not always work with people to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enables them to do the things that matter to them.

• We reviewed 11 risk assessments / risk management plans during the assessment. Risk assessments were all up to date and had been updated following incidents.
• Levels of restraint, rapid tranquilisation, seclusion and long-term segregation were low. In the 6 months prior to our inspection, there had been 14 restraints across all 4 wards and no incidences of prone restraint. There had been 2 instances of rapid tranquilisation across the service. There had been no incidents of seclusion and 2 incidents of long-term segregation.
• Not all wards had a seclusion room. Staff used a hospital car to transfer patients when they needed to be secluded on another ward. Although there was a policy in place which provided basic guidance on how to do this, this lacked detail as to how to mitigate risks including how to support the patient whilst the car was moving. Staff received training in carrying out restraint, but did not receive specific training in how to transfer patients using a vehicle. Following our inspection further guidance and training was developed regarding transferring patients to seclusion using a vehicle. We were concerned about the safety of patients being transported in this way. However, levels of seclusion within the forensics service were low and there had been no seclusions in the service in the past 6 months.
• Staff did not always carry out patient observations at irregular intervals in accordance with the policy. Records showed some observations were carried out at predictable intervals which increased the risk for patients who were being observed.
• Staff involved patients in care planning. Care plans reflected patient’s wishes and most patients told us they had been offered a copy of their care plans. Staff recorded when patients refused a copy of their care plans. Patients could discuss their care in Multi-Disciplinary Team meetings which took place monthly.
• Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties. Staff explained patients care plans to them in one-to-one sessions and staff made sure information was available in a range of formats, for example we saw easy read posters on some of the wards.
• Staff enabled patients to give feedback on the service they received. Staff held regular community meetings and we observed patients raising concerns with staff.
• Staff enabled patients to make advance decisions (to refuse treatment, sometimes called a living will) when appropriate.
• Staff ensured that patients could access advocacy.

We do not always detect and control potential risks in the care environment and make sure that the equipment, facilities and technology support the delivery of safe care.

• Staff carried out regular risk assessments of the care environment. The service had an up-to-date fire risk assessment and patients had individual personal evacuation plans where appropriate. However, the risk assessments did not identify all risks we found on inspection. Not all radiators had radiator covers which meant there was a risk of patients getting burnt, however the provider told us these were in low risk supervised areas. There was wooden decking in the garden on Wainwright ward which was rotting and exposed nails were protruding from the broken wood, which presented a health and safety hazard. We shared these concerns with the provider during our inspection and they took immediate actions to mitigate the risks to patients. There were also areas of drainage grating which were missing which were a trip hazard. Some of the flooring by the door to the garden on Arkwright ward was uneven and presented a trip hazard. The heating varied significantly between different rooms. There was a sports hall that was very hot and a family room and multi faith room which were cold. Patients told us that rooms were often too hot or too cold and said that it could take several months to get the heating adjusted. Staff on Wainwright ward told us the upstairs lounge area was too hot in the summer. It had large windows in the roof with no blinds to protect patients from the sun.
• The ward layout did not always allow staff to observe all parts of ward. However, parabolic mirrors had been put in place in most blind spots to support staff carrying out observations. The service had a list of mirrors still needed to support staff in observing areas where there were blind spots, there was some mitigations in place such as implementing appropriate observations levels for vulnerable patients, however it was not entirely clear how each blind spot was mitigated.
• Managers had completed ligature risk assessments for all areas of the hospital. Most ligature risk assessments were up to date however, the garden and courtyard risk assessment for Kenton ward was due for review in May 2023. Staff had mostly mitigated the risks adequately and staff completed a ligature risk booklet to help them identify ligature risks in an environment. However, there were no records of local inductions when staff were moved between wards and we were therefore not assured that all staff were up to date with all the risks on the wards they were working on. This was addressed during our inspection.
• Staff had easy access to alarms and patients had easy access to nurse call systems, however there was insufficient alarms for visitors to the wards. The provider told us that mitigation were in place such as carrying out risk assessments for unexpected visitors to the wards, where there was not an alarm available.
• The service had 2 seclusion rooms, one of these was on Arkwright ward and one on Wainwright ward. Seclusion rooms allowed clear observation and two-way communication and had toilet facilities and a clock. On the day of our inspection one of the seclusion room intercoms was not working. This was raised and fixed during our inspection.
• Clinic rooms were neat and tidy and fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly. However, on Kenton ward we found 1 medicine and some medical equipment which were out of date.

We make sure there are enough qualified, skilled and experienced people, who receive effective support, supervision and development and work together effectively to provide safe care that meets people’s individual needs.

• There were sufficient staff in the hospital to meet patient’s needs. At the time of our inspection the hospital had no vacancies. The turnover rate for the hospital was 14.8% and the sickness rate for the hospital was 1.45%. The hospital used low numbers of agency staff. Between October 2024 and March 2025, the service had used 29 nursing agency shifts, which were all night shifts and 2 healthcare worker agency shifts. Across the same period, the service had used 98.4 nursing bank shifts and 681.1 health care worker bank shifts. Managers told us that bank staff were usually familiar to the ward.
• Managers had calculated the number and grade of nurses and healthcare assistants required and the number of nurses and healthcare assistants matched this number on most shifts. The ward manager could adjust staffing levels daily to take account of case mix.
• When agency and bank nursing staff were used, those staff received an induction and were familiar with the ward. However, staff were sometimes moved between wards and there were no records of these staff having received a local induction for the new ward they were working on. This meant, there were no assurances that staff knew the layout of the wards and had knowledge of environmental hazards such as ligature risks and local fire procedures.
• Staffing levels did not always seem to allow patients to have regular one-to-one time with their named nurse, we saw evidence of one-to-one sessions recorded but these did not always appear to be regular and some patients told us that they had to request one to one sessions in order to receive them.
• Staff shortages rarely resulted in staff cancelling escorted leave or ward activities.
• There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency.
• Staff had received and were up to date with appropriate mandatory training. The overall training compliance for the service was 93%. The training was appropriate for the patient group using the service and included reducing restrictive intervention and breakaway training, basic life support with defibrillator training, the Oliver McGowan mandatory training on learning disability and autism tier 1 and 2 and diversity and inclusion training.

We do not always assess and manage the risk of infection, detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.

• Not all ward areas were clean or well-maintained. Some of the bathrooms and toilets were not clean, there was algae covering one of the outdoor shelters and some of the rehab kitchens and the café kitchen were not clean. Areas of the ward were poorly maintained. Some rooms across all wards had peeling paintwork and wallpaper coming away from the wall. There were bathrooms that had flooring that was coming away from the wall which was an infection control risk.
• Cleaning records were up to date; however, not all of the records were accurate. Cleaning audits took place and these identified some but not all of the concerns we found during our visit. For example, we found a number of the ward kitchens were not clean with stained and dirty walls and these areas did not appear to be included in the cleaning audits.
• Staff adhered to infection control principles, including handwashing. However, some of the handwashing gel containers were empty, although we were told staff had access to nearby handwashing facilities.

We make sure that medicines and treatments are safe and meet people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happen.

• Staff followed good practice in medicines management (that is, transport, storage, dispensing, administration, medicines reconciliation, recording, disposal, use of covert medication) and did so in line with national guidance. Clinic rooms were clean and tidy and staff carried out emergency equipment checks and fridge temperature checks in line with their policies and procedures. Medicines were mostly in date, although on Kenton ward we found some out of date equipment and 1 medicine that was out of date.
• Staff reviewed the effects of medication on patients’ physical health regularly and in line with NICE guidance, especially when the patient was prescribed a high dose of antipsychotic medication. We reviewed 12 medicines records; all of these were accurate, had appropriate mental health paperwork and consent forms in place and staff were carrying out relevant monitoring for patients on high dose antipsychotic medicines. Staff supported patients to self-medicate where appropriate.