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 maintaining a safe environment. There were gaps within communal doors and some bedroom doors throughout Kemple View. The service has issues with their heating which have been on the risk register since 2023.

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.

During the 12 months prior to assessment there had been 10 serious incidents across both forensic and rehabilitation wards within Kemple View. Themes were analysed, with serious incidents most commonly involving physical assault and patient absence without leave (AWOL). Actions and lessons learned were discussed in multi-disciplinary team meetings, with strategies identified to reduce physical assaults in the future. The service had appointed an incident supervisor to ensure accurate timelines and record keeping of incidents. They also provided new guidance for staff, which had been cascaded with the expectation for staff to followthis should a patient go AWOL.

Staff knew what incidents they should report, who to report them to and how to report them. Staff received feedback fromthe investigation of incidents, both internal and external to the service and met to discuss that feedback. There was evidence that changes had been made because of feedback. The service was able to provide information about improvements in safety specific to this service. 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 prior to admission, 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 met 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 that when appropriate.
• 97% of staff on Oakwood ward and 100% of staff on Hawthorn ward had completed Safeguarding Adults Level 1 and 2 and Safeguarding Children Level 1 and 2.
• Compliance with Safeguarding Level 3 was at 96.9% for Hawthorn ward and was at 96.2% for Oakwood ward.
• 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. Kemple View had a family room, which was in a separate building within the grounds of the hospital.
• At the time of our assessment 97% of staff on Oakwood ward and 100% of staff on Hawthorn ward had completed the company’s Reducing restrictive practice and intervention breakaway training (RRIT) course.
• Although RRIT covered transporting a patient, at the time of our assessment, there was no specific training for staff on how to safely transport patients via a vehicle in this manner. Kemple Views policy lacked detail, it did not detail the minimum number of staff members needed for safe transportation.

We do 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.

• Not all wards had a seclusion room. Within the grounds of Kemple View there were two seclusion rooms, both of which were located on the forensic wards. These wards were located in a separate building to the rehabilitation wards. The hospital’s policy stated that should seclusion be required for patients on either of the rehabilitation wards then they should be transported there using a hospital vehicle.
• Between 2 November 2024 and 27 December 2024 hospital vehicles were used by staff to transport patients from Hawthorn and Oakwood rehabilitation wards to a seclusion room on 5 occasions. The service had advised the transfer would take roughly 2-3 minutes. Although there was a policy in place which provided basic guidance on how patient transfers should be conducted, this lacked detail as to how to mitigate risks to both patients and staff.
• Individual service user risk assessments were not carried out in relation to the use of this method of transport. Since this inspection, Kemple View have acknowledged the need for a new transfer checklist.
• At the time of our assessment, staff had not received specific training in how to transfer patients using a hospital vehicle. Kemple View’s ‘transfer patient to another ward’ policy was insufficient as for example, it did not detail the type of vehicle that should be used or the minimum number of staff members required for safe transportation. Reducing restrictive practice and intervention breakaway training (RRIT) compliance was 100% for Hawthorn ward and 97% for Oakwood ward.
• Mechanical restraint (the use of a physical device to restrict a person's movement) had been used on one occasion on Hawthorn ward. The service did not have a policy relating to the use of mechanical restraint on the rehabilitation wards. This meant that mechanical restraint was being used to restrain a patient without the required risk assessment or safeguard being put in place.
• Staff did not always carry out observations at irregular intervals in accordance with the provider’s policy. Some observations were carried out at predictable intervals which could mean that patient risks were not managed effectively.
• 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 in the wards.
• On Hawthorn ward a translator was used in ward rounds to support a patient whose first language was not English, to understand their care and treatment. The use of picture cards and google translate was also used to enable staff to communicate with this patient.
• 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 ensured that patients could access advocacy.
• We reviewed 6 patient risk assessment and risk management plans during the assessment. All 6 risk assessments were up to date.

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

• The service had an up-to-date fire risk assessment and patients had individual personal evacuation plans where appropriate.
• The most recent fire risk assessment highlighted a hazard in that communal doors and various bedroom doors throughout Kemple View had an excessive gap between the door and frame. The fire risk assessment stated that the provider should take action to ensure that all doors closed fully into the rebate and gaps around the door were not more than 4mm. The service had not provided a plan or a timescale to when this was to be actioned.
• We identified potential ligature anchor points on fire doors on the wards. These ligature points were not identified on the service’s ligature and blind spot action plan. We were told the potential ligature risk of the internal corridor fire doors were mitigated by staff observations, and the use of parabolic mirrors. However, some observations were conducted at predictable intervals and there was not always a member of staff present in these areas.
• Legionella testing and portable appliance testing were in date. The overall legionella residual risk for Kemple View was high but the service was taking action to manage this risk.
• We found a radiator that did not have radiator covers which meant there was a risk of patients getting burnt, however the provider told us these were in low risk, supervised areas. Radiators also posed a potential ligature risk. This was highlighted by the service in 2024 within the service ligature and blind spot action plan. The service action was that all radiators on Oakwood ward were to be replaced by June 2025.
• Staff had easy access to alarms and patients had easy access to nurse call systems.
• Hawthorn and Oakwood wards did not have seclusion rooms. If patients from these wards required seclusion they were transferred to a seclusion room on either Wainwright or Arkwright forensic wards within Kemple View grounds via a hospital vehicle.
• Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.

Quality Statement Score:3

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.

• The staff turnover rate for the hospital overall was 14.8% and the staff sickness rate was 1.45%.
• At the time of our assessment Oakwood ward had 2 vacancies. During our assessment staff explained should they be short staffed, shifts would be covered by staff within the service in the first instance and if this wasn’t possible then they would reach out to regular bank staff who knew the patients.
• The service used agency workers and bank staff to cover shifts. The hospital used low numbers of agency staff.
• Between October 2024 and March 2025, 11-night shifts were covered by qualified agency nurses.
• During the same period qualified bank nurses covered 19.2-day shifts. They used 17.6 nursing bank shift for the night. Managers told us that bank staff were usually familiar to the ward. They used 17.6 nursing bank shift for the night
• Staff shortages rarely resulted in staff cancelling escorted leave or ward activities. One patient told us their leave was cancelled due to no cars being available and this was confirmed by staff.
• Staff had received and were up to date with appropriate mandatory training. The overall training compliance for the service was 93%.
• There was adequate medical cover day and night, and a doctor could attend the ward quickly in an emergency.

We did not 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. In January 2025, the outcome of the service’s cleaning audit was that Hawthorn ward had failed due to patient showers and bathrooms not being in a good state of repair with cracks to the flooring. The estates team were aware of the concerns and were making plans to address them.
• Staff maintained equipment well and kept it clean.
• Cleaning records were up to date but did not consistently demonstrate that the ward areas were cleaned regularly. We identified gaps in the cleaning record for the clinic room in Hawthorn ward . There were 8 gaps in January 2025 and 4 gaps in February 2024. However, ward areas were noted to be visibly clean during our assessment and cleaners were visible whilst we were on site.
• Staff adhered to infection control principles, including handwashing.

We did not always ensure 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.

• We reviewed 13 patient medicines records. Most, but not all of these were accurate. We identified 2 errors in the recording of medication on Oakwood ward; we highlighted these to staff during our assessment and were rectified immediately. On Hawthorn ward one patient had been prescribed medicines for agitation/anxiety, which was not detailed on their treatment form.
• On the whole, 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. However, during our inspection we identified an open controlled drug bottle (morphine) which had the wrong expiry date on. This was rectified on site during our assessment and was disposed of immediately.
• Patients told us although they are able to speak to staff about their medication, however some patients told us their medication was not always reviewed with them.
• Staff were conducting relevant monitoring for patients on high dose antipsychotic medicines.
• Staff reviewed the effects of medication on patients’ physical health regularly and in line with NICE guidance.