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 legislation. Regulation 15 HSCA (RA) Regulations 2014 Premises and equipment. The service had made improvements and is no longer in breach of regulations. At this assessment the rating is good.

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 69 (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 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.

There had been no serious incidents reported on Wortham ward or the bungalows in the last 12 months. We reviewed 6 incidents on Wortham ward they were clearly identified and reported on the computer system. Where required safeguarding and police were involved. Review of incidents were timely, de-escalation and debrief with patients took place where necessary. We did, however, find that incidents were not shown on the list of incidents in patient records.

Staff described the incident reporting process and knew when and how to complete incident reports. They told us incidents may be reviewed at a team review. Leaders reviewed lessons learnt from incidents and shared with all staff across the hospital by email and discussed at clinical governance meetings and in team meetings. The hospital had a monthly learning lessons bulletin, which was shared across the hospital. This meant staff could learn lessons from incidents elsewhere. Managers demonstrated good oversight of incidents on their wards.

is. On Wortham ward staff took keys home in error. Following this incident, stricter systems were put in place, managers gave out keys to one person and staff did not change keys between themselves.

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’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. In Wortham ward initial assessments were carried out by the manager and specialist doctor. In the bungalows initial assessments were carried out by the psychiatrist and psychologist. Referrals were often received from out of county but carers of patients in the bungalows told us that the hospital provided good care which could not be found nearer to home.

The environment in each bungalow was adapted for the needs of the individual and they had a long transition prior to moving in, which involved staff from the hospital spending time with the new patient in their current hospital.

Medical staff described how they planned as a team and developed a risk assessment and plan for managing the risks of an individual prior to their admission. Staff made referrals to other hospitals if they could not accommodate. Patients were able to move between the wards in the hospital if their needs changed. Wortham managers described how not all referrals were suitable for the ward due to having a first floor with no lift.

Discharge was discussed at weekly multi-disciplinary team (MDT) meetings. Staff described how they had good communication with services where their patients moved to. Community teams supported the wards with discharge.

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 had received training in safeguarding and knew how to make a safeguarding alert. Staff described who they contacted if they needed to raise a safeguarding alert. The safeguarding leads from the hospital liaised with external safeguarding teams.

Staff compliance with level 3 safeguarding training for adults and children across the service was 93.5%. We observed on Wortham ward posters displayed advising patients of the safeguarding leads and how to contact them. Staff described instances when they had involved safeguarding leads to advocate for patients on the wards. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. On Wortham ward the managers described how police investigated incidents.

Leaders told us how blanket restrictions were reviewed monthly based on the least restrictive practice, there was a subcommittee for reducing restrictive interventions and staff told us each ward kept a register.

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.

We reviewed all 4 care records in the bungalows, all records had risk assessments in place and were regularly updated by staff. Each risk assessment highlighted the risks for patients including mental health, physical health, behavioural and social risks. In Wortham ward we reviewed 4 care records, they all had risk assessments and risk alerts in place and were updated regularly. We saw risk management plans and patients had Positive Behaviour Support Plans (PBS). There was evidence of professional involvement and interventions in place.

There were no incidents of prone (face down) restraint or rapid tranquillisation on these wards. There were no incidents of restraint on Wortham ward. There was 1 patient being nursed in long term segregation from Wortham ward following patient-on-patient assaults. The hospital had a Reducing Restrictive Practice Policy.

In the bungalows between February and August 2025, there were 57 incidents of no harm or minor harm. Staff had used light holds; redirection or verbal techniques and patient debrief in all instances.

We observed a chart in a bungalow which showed incidents had reduced for this patient. The patient displayed certificates of appreciation, visual reminders on the walls and a mutual expectations folder, staff described how these methods had a positive impact and had reduced incidents.

Staff told us on Wortham ward restraints were very rare and, in the bungalows, staff described how they used light holds when restraint was required but generally how they reassured and deescalated the situation. Staff on Wortham ward explained how each patient was risk assessed to see if they were able to use the bathroom on their own.

In the bungalows staff involved patients in care planning and risk assessment, carers participated in multidisciplinary team reviews. However, on Wortham ward there was little or no evidence of patient involvement in care planning, but patients and carers were invited to multi-disciplinary team (MDT) meetings.

Staff ensured that patients could access advocacy, we saw posters displayed showing patients how to obtain an advocate and heard from staff and saw in care plans, patients had advocates. Patients told us there was enough information of how to access an advocate.

Patients attended community meetings and patient ward representatives attended patient council meetings.

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.

During an inspection in January 2020, the provider had the following breach: The provider must ensure that all emergency equipment is properly stored, and easily accessible and that all staff know where to locate it. During this inspection, the service was no longer in breach of regulations.

The wards overall looked old and tired and had maintenance issues waiting to be completed. The hospital had a head of facilities who conducted health and safety audits. Wortham ward was having a refurbishment upgrade of toilets and bathrooms with further planned works including new dining areas, a new kitchen and flooring. This did impact on the number of working bathrooms for patients who could not all access the first floor as there was no lift. After our visit, leaders told us and we saw photo evidence, that Wortham ward had been painted, and the bathrooms had been refurbished, and patients had given good feedback.

In 1 of the bungalows there was a chimney stack flashing leaking, which was impacting on the patient in this bungalow, the hospital gave assurance this was being repaired urgently. However, staff told us maintenance were responsive and quick to carry out repairs.

Despite cleaning records showing that cleaning had been conducted regularly, Wortham ward was not clean. The conservatory on Wortham ward had basic furniture and, in the garden, the furniture was worn and the windows in the conservatory looked murky.

Staff completed ligature risk assessments and had mitigated the ligature risks adequately. Ligature cutters were in the clinic and the office. Staff told us there was a hot map in the bungalows for ligature points and staff were aware of the risks and mitigation.

There was CCTV in all the communal areas on the wards and staff carried radios. Wortham had an emergency bag in the office to be used if a patient was missing, including emergency mobile numbers.

Fire extinguishers were up to date with their checks, and there was emergency lighting in the halls. The manager completed regular out of hours environmental tours of Wortham ward.

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.

Across the hospital we observed good staffing levels. There were 2.2 registered nursing vacancies and no vacancies for health care assistants. Sickness levels stood at 2.5% and staff turnover 1.2% in the last 3 months. Managers told us there was a full multidisciplinary team (MDT) including a specialist doctor, occupational therapist, psychologist, physical health team, and dietitian.

Staff received appropriate mandatory training. Overall compliance with mandatory training was 91.4%. Training was appropriate for the patient group using the service. The hospital had a training facilitator and induction’s took place once a month on a rolling programme. Staff told us managers encouraged them to ask for extra specialist training dependant on their preferences.

Managers told us the hospital used their own trained bank staff they were regular and known to patients and other staff. Bank staff used during the months May, June and July 2025 averaged 501 shifts per month across the hospital. Managers told us bank staff must be up to date with their training and would not be offered a shift. The hospital rarely used agency staff.

Managers provided new staff with appropriate induction. Managers ensured that staff had access to regular team meetings. The percentage of staff that had had an appraisal in the last 12 months on Wortham ward and the bungalows was 100%. Across the hospital from January to July 2025, 92% of clinical staff and 100% of managerial staff had received their supervision. A staff forum took place once a month.

We scored the service as 2. The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Despite cleaning records showing that cleaning had been conducted regularly, Wortham ward was not clean, including the communal dining room, conservatory and the vacant rooms we viewed. We spoke to leaders about the cleaning on the ward, in agreement that the cleaning required review.

Staff maintained equipment well and kept it clean with visible stickers which were in date. Staff adhered to infection control principles, including handwashing.

The service had a programme of Infection Prevention Control (IPC) audits as part of the hospital’s audit programme included regularly across the year. These included cleanliness audits for all areas, hand hygiene, mattress audit, cleanliness audit for patient facing areas.

Staff followed the infection control policy, including handwashing. Staff compliance rate for infection prevention control training 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.

The clinic rooms on wards were clean, organised and there was evidence of good record keeping and clinical audits. We reviewed 6 prescription records across the service. Staff prescribed and administered medication safely. One patient was on higher medication dose than British National Formulary (BNF) limits, however there was evidence of High Dose Antipsychotic Therapy (HDAT) monitoring in place. There was evidence of physical health and side effects monitoring and no overuse of PRN (as and when) medications.

Allergies of each patient were checked and recorded. The Pharmacists carried out weekly audits on all medications to check they’re within the BNF levels and gave staff any actions. The doctors met with the pharmacist and reviewed any errors and agreed how to reduce these.