Kneesworth House

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 requires improvement. The service was in breach of regulation 13 (safeguarding service users from abuse and improper treatment) and regulation 17 (good governance). The service had made improvements and is no longer in breach of regulations. At this assessment the rating has changed to good.

This meant people were safe and protected from avoidable harm.

All wards were safe, clean well equipped, well furnished, well maintained and fit for purpose. Staff assessed and managed risks to patients and themselves well. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service used systems and processes to safely prescribe, administer, record and store medicines. The service managed patient safety incidents well.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

During an inspection in 2020, the provider had the following breach: The provider must ensure essential learning and information is passed between the hospital’s senior management team and the ward managers and that this is shared with all staff and recorded appropriately. During this inspection, this had improved. Service leaders attended a morning meeting where any incidents and identified learning was discussed. We saw evidence of learning being shared with all staff, and staff were able to provide examples of learning that had been shared with them.

Staff reported serious incidents clearly and in line with provider policy. Staff knew what incidents to report and how to report them. Staff recorded incidents on an electronic incident reporting system. All incidents were reviewed and signed off by the ward manager or a deputy ward manager. Staff understood the duty of candour. They were open and transparent and gave people a full explanation if and when things went wrong.

The service understood its responsibility to submit statutory notifications. Governance processes showed leaders had oversight of incidents and took action to manage risks.

Managers investigated incidents thoroughly. They reviewed incidents and identified any themes or trends. Information from these discussions was reported up to clinical governance meetings. Leaders reviewed lessons learned, issues requiring support to resolve and areas of good practice in clinical governance meetings.

Staff met to discuss learning from incidents which was shared in a variety of ways. Staff told us they received regular communications about learning from incidents via email. If an incident took place on their ward, it would always be discussed in handover, and staff told us they received debriefs following serious incidents. Leaders from the PICU service told us they attended provider level PICU network meetings where they discussed serious incidents and shared learning and best practice.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service received referrals from across England. However, Bourn ward held a contract with a local NHS trust whereby all admissions were referred by the trust. Ward teams met to discuss new referrals to ensure they could meet the needs of the patient and maintain the safety of all patients on the ward. Ward teams liaised with the senior leadership team and were supported by them if a decision was made not to accept a referral.

Some wards had an exclusion criteria. For example, Nightingale ward was situated across 2 floors, therefore the ward was unable to accept patients with mobility issues who were unable to access stairs independently. 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 health and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. Other agencies involved with patients’ care were invited to attend ward rounds and could attend virtually if that was preferred.

Staff ensured that patients’ discharges from the service were managed safely. Discharge planning began at a patient’s first ward round. Patients were either transferred to another placement closer to home when appropriate or discharged to their own accommodation. Staff liaised with the appropriate services to ensure robust discharge plans were in place. Where appropriate, patients often had a period of trial leave before they were discharged. Staff on Bourn ward told us they carried out follow up calls to patients once they were discharged and ensured they contacted the patient’s care coordinator.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff received training on how to recognise and report abuse, appropriate for their role. Staff compliance with level 3 safeguarding training for adults and children across the service was 93.5%. Safeguarding leads were identified within the service and there was an overall safeguarding lead for the hospital.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff gave us examples where they had raised safeguarding concerns relating to physical abuse between patients.

Staff knew how to recognise adults and children at risk of or suffering harm and worked with other agencies to protect them. The service had developed a good working relationship with the local authority and submitted safeguarding referrals appropriately.

Staff followed clear procedures to keep children visiting the ward safe. Children were not permitted to visit patients on the wards. Visits from children took place at other areas in the hospital.

There were clear procedures in place to promote people’s safety. The safeguarding adults and children's policies provided guidance to ensure staff were aware of how to raise a safeguarding concern. Safeguarding noticeboards in the ward offices also provided contact details for the local safeguarding authority, as well as who the safeguarding leads were.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff used restraint and seclusion only after attempts at de-escalation had failed. The ward staff participated in the provider’s restrictive interventions reduction programme. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

During an inspection in January 2020, the provider had the following breach: The provider must ensure that patients’ access to room keys, bedrooms, mobile phone chargers and outdoor space are only restricted where this is required through individual risk assessment. During this inspection, the service was no longer in breach of regulations. Patients were able to access their room keys, bedrooms, mobile phone chargers and outdoor space as they wished, unless restrictions were required for individuals which were recorded in individual risk assessments.

Staff completed risk assessments for each patient on admission using a recognised tool, and reviewed this regularly, including after any incident. We reviewed 9 risk assessments during the inspection. Most of the records included associated management plans where risks had been identified, however there was limited evidence of collaboration with patients in the development of the management plans. We found some safety plans were missing or lacked detail.

Staff made sure patients’ care plans were up to date. Staff involved patients in care planning in most of the records we reviewed. Some patients were offered and accepted a copy of their care plan. Patients were given the opportunity to participate in their ward round reviews. Most care plans we reviewed were personalised to the individual and some care plans were holistic.

Staff identified and responded to any changes in risks to, or posed by, patients. Staff used de-escalation techniques to initially respond to situations of risk. The multidisciplinary team discussed incidents and changes to patients’ risks at handover meetings and ward rounds. Staff responded to risks by reviewing medication, observation levels and access to leave.

Staff followed provider policies and procedures when they needed to search patients or their bedrooms to keep them safe from harm. Staff said they conducted room searches when they suspected that a patient had prohibited items. Staff routinely searched patients when they returned from leave.

Staff participated in meetings to review blanket restrictions and try to reduce them. All managers were required to submit their blanket restrictions which were reviewed monthly and through audits. Staff provided examples of restrictive interventions that were reduced, such as patients used to have set times to vape, however this changed to enable patients to use their vapes at any time.

Levels of restrictive interventions were consistent with other similar services. Between 1 February 2025 and 14 August 2025 the service recorded one incident where prone restraint was used. This meant that the patient was restrained facing the ground. There had been a total of 89 instances of rapid tranquilisation across the service, with 72 of those taking place on Wimpole, 11 on Bourn and 6 on Nightingale. Staff recorded incidents thoroughly and ensured that all details were captured clearly and consistently.

During an inspection in January 2020, the provider had the following breach: The provider must ensure staff seclude patients and record seclusion in line with the Mental Health Act Code of Practice and the provider’s policy. During this inspection, the service was no longer in breach of regulations. We reviewed seclusion documentation for 5 patients and found that it was completed appropriately.

The seclusion room on Wimpole was not in use at the time of the inspection as it needed to have a new door fitted. Staff on Wimpole were able to use the seclusion room on Bourn if required, as it was situated in the same building. Nightingale did not have a seclusion room. It was detailed in the eligibility criteria for the ward that patients would not be admitted if they required seclusion, however staff made appropriate arrangements in order to access Bourn seclusion room in the event it was required. Evidence showed only 3 occasions in the last 6 months where a patient from Nightingale required seclusion on Bourn, which showed the eligibility criteria was being followed.

Staff enabled patients to give feedback on the service they received through regular community meetings. Patients we spoke to described these as useful and constructive meetings where they felt listened to, and that changes were made as a result of their feedback. For example, staff on Wimpole ward told us they changed the coffee given to patients following feedback received in the community meeting.

Staff ensured that patients could access advocacy. All patients we spoke to during the inspection told us they were able to access an independent advocate.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure equipment, facilities and technology supported the delivery of safe care.

Staff completed thorough risk assessments of all ward areas and removed or reduced any risks they identified. For example, staff completed ligature point and blind spot audits. These were comprehensive documents, covering all areas of the wards and external areas. Staff conducted daily environmental checks of all the wards.

The service complied with NHS guidance on delivering same-sex accommodation. Wimpole and Nightingale were same sex wards. Bourn was a mixed sex ward, but there were separate bedroom corridors for males and females with separate bathrooms. There was also a female only lounge available.

Patients had easy access to nurse call systems in their bedrooms.

Seclusion rooms allowed clear observation and two-way communication, and had toilet facilities and a clock. The seclusion room in Wimpole was out of use at the time of inspection. The seclusion room in Bourn was used by the whole service as required.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.

There was an issue with some maintenance requests being picked up in a timely manner by the maintenance team. For example, the blind spot audit tool identified areas of Wimpole that required mirrors to be fitted. The audit was dated 27 August 2024. This was raised during the inspection and the maintenance team reviewed the requests. Staff informed us that there had been a loss of data on the intranet so some maintenance requests had needed to be resubmitted. Staff mitigated the risks posed by the mirrors not being in place through carrying out observations and the use of CCTV footage.

Staff did not always have access to alarms. The service was in the process of updating its alarm system. Some staff were using radios whilst some still had access to alarms. There were inconsistencies on how to raise an alarm, and we were concerned this could affect response times.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The service had enough staff to keep people safe. Data provided by the service identified 2.1 whole time equivalent (WTE) registered mental health nurse vacancies across the hospital. There were no vacancies for healthcare workers and the hospital was actually over establishment. Turnover of staff for the last 3 months was 1.2% against a target rate of 3.5%. Staff sickness for the last 3 months was 2.5% against a target rate of 3.5%.

The service had a proactive system for arranging staffing which was also flexible to adjust to changes. The hospital always operated with 2 more staff than needed daily to ensure any gaps could be immediately filled, or to ensure leave and other activities could be facilitated. The ward manager could adjust staffing levels daily to take account of need. For example, if patients required constant observations, the corresponding number of staff required were added to the required numbers.

When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels. When agency and bank nursing staff were used, those staff received an induction and were familiar with the ward.

Leaders monitored unfilled shifts. Over the last 3 months prior to the inspection there was 1 unfilled shift in May 2025, 3 unfilled shifts in June 2025 and 7 unfilled shifts in July 2025. These figures applied to the whole hospital. The hospital utilised a contingency plan in the event of being short staffed whereby ward managers or lead nurses could be included in the staffing numbers to ensure there was no disruption to services.

There were enough staff to carry out physical interventions, for example, observations, restraint and seclusion safely. 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. Overall compliance with mandatory training was 91.4% The training was appropriate for the patient group using the service.

Staff received regular supervision monthly. Managers monitored compliance with supervision. Reasons for supervision not taking place were documented and mostly included staff members being off sick or on leave.

Staff were given a comprehensive induction to the service to ensure they were prepared for the role. Managers monitored staff competencies on an annual basis to ensure staff were competent to carry out their duties. The competencies monitored were medication (for registered nurses), seclusion and observations.

Leaders supported staff to develop through yearly, constructive appraisals of their work. 100% of staff across the service were up to date with their appraisal at the time of the inspection.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service conducted a number of infection prevention and control (IPC) audits as part of the hospital’s audit programme. Staff carried out annual audits in IPC compliance, hand hygiene and mattresses. Staff audited the cleanliness of all areas and patient facing areas 2 times per year.

Housekeeping staff cleaned the wards daily. We observed that all ward areas were clean, furniture across the service was in good condition, however some of the décor appeared tired in places. There were plans for refurbishment on Wimpole ward the following year.

Staff followed infection control policy, including handwashing. Staff compliance rate for infection prevention control training was 95.2%.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Staff followed systems and processes to prescribe and administer medicines safely. Staff kept a record of all medicines dispensed on a medicines administration record. A specific record keeping system was in place for controlled drugs.

Staff reviewed each patient’s medicines regularly and provided advice to patients and carers about their medicines. Patients’ medicines were reviewed as part of ward rounds. Staff provided information about possible side-effects. Patients were involved in discussions about medication and care planning. One patient specifically said they had spoken to their doctor about their medication.

Staff completed medicines records accurately and kept them up-to-date. We reviewed the medicines charts for 15 patients. Records we looked at were clear, up to date and accurate. The system used by the service for administrating medicines was held on a highly effective electronic system which minimised the possibility of errors occurring.

Staff stored and managed all medicines and prescribing documents safely. All medicines were stored in locked cabinets, or in the medicine fridge, in the clinic room. The temperature range for the medicine fridge was 2-8 degrees Celsius. Staff monitored fridge temperatures and there was a process in place for staff to follow if temperatures were outside of range.

The service ensured people’s behaviour was not controlled by excessive and inappropriate use of medicines. The majority of patients received doses of medicine within the level recommended in the British National Formulary (BNF). Where medicines were prescribed over this limit, a high dose antipsychotic (HDAT) review was completed and reviewed appropriately.