Roy Kinnear 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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.
This is the first assessment for this newly registered service. This key question has been rated 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 the ways people’s medicines were managed.

This service scored 53 (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 always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Staff understood their safeguarding responsibilities and said incidents were reported to the clinical lead. Meeting records showed that learning from a recent safeguarding incident had been discussed with the wider team.

However, some incident records were incomplete. For example, bruises were recorded on a body map without any corresponding incident report, follow-up documentation, or investigation into the cause. When queried, staff confirmed that the clinical lead managed such incidents, but they were unsure whether this specific incident had been reported. This inconsistency reduced assurance that safeguarding procedures were applied consistently and followed up with timely action and shared learning. As a result, the service’s ability to drive continuous improvement was limited.

The provider 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 provider worked with people and healthcare professionals to establish safe systems of care. People were supported by hospital teams, general practitioners, district nurses, and other allied health professionals. Transitions into the service were planned and risk assessed in partnership with external professionals, including education providers.

We saw evidence of structured transition plans to support safe admissions. For example, one person had moved from an education setting following a coordinated transition involving multiple teams. Pre-assessment documentation was completed, and family members were involved in the planning process.

Staff supported people during hospital visits with the use of hospital passports and made efforts to ensure clinicians were familiar with people’s needs. Staff also contributed to discharge planning to support people returning to the service safely.

A relative commented, “My relative is happy and settled at Roy Kinnear House. I think they feel both safe and well cared for. I am very happy that they are close to home, but in a nurse-led setting that supports their complex needs.”

Staff were able to describe what safeguarding is and how to recognise the different types of abuse. People appeared to be well cared for and feel relaxed around staff. Staff training included safeguarding training, and this was also a topic for discussion in the provider’s observation record.

Staff were confident they could spot any concern and act promptly to ensure the safety of residents. Staff explained the service’s process of reporting concerns and gave examples of what constitute a safeguarding concern.

However, this was not consistently translated into effective practice. Records showed that while 3 safeguarding incidents had been formally recorded over the last year, body maps showed bruising that had not been explored or recorded as incidents. We did not see documented follow up or investigation of bruises noted on body maps. We also saw some records of behavioural charts kept for people where it had been recorded that they were in distress but there was no evidence of these concerns reported as incidents. When we queried this, staff explained that these were being reviewed by the positive behaviour support lead. We did not see evidence of such review or escalation.

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

Risk assessments were in place and regularly reviewed for most people. Staff used their knowledge of people’s communication styles to involve them in everyday decisions and encourage participation. Staff involved people in organising their rooms and were attentive to gestures and facial expressions. People were supported by skilled staff who understood their conditions. We saw evidence that staff were trained to support people with their dietary needs and epilepsy. People with behavioural concerns had a positive behaviour support plan in place which staff said helped them to spot any signs of escalation and they were able to apply the strategies in the plan to support people safely.

Notwithstanding the above, people were not consistently supported to manage risks associated with their care. Individual risk assessments, such as for moving and handling were out of date. While some care plans were reviewed, these reviews were generic and lacked details of what had been reviewed. The provider lacked a robust process to ensure timely updates. This meant that people’s risks were not effectively managed or changes correctly documented.

Staff reported that training on Percutaneous Endoscopic Gastrostomy (PEG) feeding was not sufficient and said they would benefit from more hands-on learning. They explained this affected their confidence in delivering complex care, as all people supported at the time of the assessment were receiving PEG feeds. The provider assured us that only registered nurses were delivering PEG feeding support and that this formed part of their competency training. However, the provider acknowledged these concerns and told us they were in the process of reassessing competencies to ensure all relevant staff felt confident and adequately supported.

The provider did not always detect and control potential risks in the care environment. Wheelchairs, shower trolleys, hoists and lifts were serviced and regularly checked to ensure they were safe. Water temperature checks were being carried out, and records showed they were maintained at safe levels. Bed rails, levers, mattresses, and essential equipment were available and in working order. Fire doors were regularly checked and found to be functioning properly.

We saw an exposed wiring in a person’s bedroom and when we queried this, we were told it was an old Television cable. The provider took an immediate step to flag it up with the housing officers who explained it had been isolated and did not pose any risk, and it had been scheduled to be boxed in.

The garden and sensory room were cluttered and were not currently in use. We were told this was temporary because of a recent bed bug infestation where things had to be removed from the main building to be treated.

While some checks were carried out and were in date, we could not be assured that there was clear oversight to ensure a safe environment. This was because the provider’s health and safety audits had not been consistently carried out each month, as required by their own policy, which states that monthly audits must be completed. Audits had not been completed between the months of January and April. This meant that several opportunities to spot anything unsafe in the environment had been missed. We also saw 1 Personal Emergency Evacuation Plan on file that were outdated and for a previous placement. We were told that things were currently being looked into, and an action plan is being put in place to address these concerns.

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 work together well to provide safe care that met people’s individual needs. Recruitment checks, including Disclosure and Barring Service (DBS) and references, were completed before staff began working. Induction included 2 weeks of training, with an additional 3 days of shadowing. Both face-to-face and online learning were part of the induction process. Most mandatory training had been completed, according to the training matrix. During our visit, we observed that while some people were supported to attend a planned activity outside the home, 1 individual who had also been scheduled to attend were unable to go due to insufficient staffing levels. Staff explained that the service were running on the minimum staffing levels for the day, and this had been a pattern for some time. Staff rotas showed that the staffing level was not always met.

A family member commented “I am deeply concerned about the impacts of lack of leadership and staffing on the morale and wellbeing of the hard-working team. We have been made aware that the care team are operating under minimum staffing levels and it's obvious that staff are working extremely hard to support the people diligently in the home. The nursing team are also under pressure and working very hard. I have the same concerns about their ability to withstand the pressure for much longer and impacts on their wellbeing.”

Although the service was safely covered, limited staffing had an impact on people's ability to consistently access planned activities.

The provider did not consistently assess or manage the risk of infection or ensure appropriate control measures were in place to prevent its spread. Handwashing signs were clearly displayed, and supplies of soap, paper towels, and pedal bins were available throughout the premises. Personal Protective Equipment (PPE) was accessible and appropriately used. However, there were no formal cleaning schedules or checklists in place. Staff told us they carried out the cleaning, but the absence of a structured system limited assurance that all areas were consistently maintained to a high standard.

No infection control audit had been carried out in 2025 at the time of our inspection. The provider’s policy stated that these audits should be completed monthly. The provider told us that infection control checks were included within their general health and safety audit. However, we could not be assured of this, as health and safety audits were not consistently completed, with several months missed.

Staff reported that a previous bedbug outbreak had resulted in people being temporarily relocated to a hotel overnight. There was no evidence of any changes or improvements to cleaning routines or hygiene practices to prevent a recurrence. This raised concerns about the provider’s ability to respond effectively to infection control risks.

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

Medicines were stored securely and administered by trained staff. People received their medicines on time. Medicines cabinet temperatures were monitored and where it had been found to be too hot, there was a system in place to cool the cabinet. However, there were no daily, weekly, or monthly medicine checks in place, this was against the provider’s medicines policy.

The last medicines audit was completed in December 2024. Issues identified during that audit had not been addressed. The auditor had recommended immediate action and expressed a lack of confidence in the service’s medicines management systems. For example, there were excess stocks of medicines, including some that were no longer in use and others that had been carried over from the previous provider. The provider did not have a formal protocol in place for the ordering and returning of medicines. This meant there were no consistent procedures to ensure that medicines were accurately ordered, recorded, or returned when no longer required, increasing the risk of errors in stock control and safe disposal.

One person was prescribed soluble paracetamol to be administered via their PEG tube. However, we found paracetamol tablets stored in their wardrobe. Staff told us the tablets were no longer in use, but they had not been removed. This presented a risk that the incorrect formulation could be administered in error, potentially compromising the person’s safety. In another case, a handwritten increase in a behavioural support medicine frequency appeared on both the medicine chart and the pharmacy label, but there were no corresponding record of a review or best interest discussion. We were told that a review had recently taken place with a doctor but there were no evidence of such review meeting and its outcome.

An as required medicine was administered multiple times in April 2025. However, there were no records to show that staff followed the protocol outlined in the care plan prior to administration, such as offering other strategies first. This limited assurance that the medicine was used appropriately.

Additionally, there were no tracking system for medicines when people visited family homes.

While no one had come to harm, we could not be assured that medicines were being managed safely.