Kitnocks 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.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 63 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff knew what incidents to report and how to report them. A staff member told us, “We have a debrief after incidents.” The registered manager shared learning with staff through team meetings, supervision and staff communication channels.

The registered manager told us they received safety alerts from the government, local authority and CQC which informed them of upcoming risks along with themes and trends to ensure they could take appropriate action to mitigate these risks.

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. People had initial assessment documents in place which covered all appropriate areas.

The provider had a robust admissions policy in place. The registered manager described how they assessed people to establish suitability and compatibility prior to moving in. A relative told us, “The transition could not have been better, the care staff were wonderful, my relative has complex needs but the staff deal with them so well.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff mostly 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 provider shared concerns quickly and appropriately. However, we did find 1 person was being supported with a lap belt on their chair to help manage their risk of falls. This restrictive practice had not been assessed under the Mental Capacity Act, and a best interest meeting had not taken place. The provider assured us by the end of the inspection, that the Mental Capacity assessment and best interest meeting had now taken place and a risk assessment had been developed in relation to the use of the lap belt.

Feedback from relatives was mixed. Some relative’s told us they felt their loved ones were safe living in the home, and staff knew how to protect people from abuse and knew who they would report any concerns to both internally and externally. Other relatives told us people were not always safe from other people living in the home and were concerned about incidents which happened where their relative had been assaulted. We spoke with the registered manager about this who assured us of the actions they had taken to mitigate risks to people. This included, additional 1 to 1 staff, a staff member based in a corridor where most incidents occurred and alarm sensors on people’s doors to alert staff if other people entered bedrooms.

The registered manager shared concerns appropriately by following the correct reporting process and informing all relevant agencies.

Where required Deprivation of Liberty Safeguards (DoLS) were in place to legally authorise restrictions, placed on people to keep them safe.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff knew people very well and relatives told us they were involved in informing their risk assessments. People were assessed for risks of choking and risks relating to medical conditions. Some people had anxiety related behaviour which had been assessed with positive behaviour plans in place to mitigate the risk to themselves and other people. Staff were responsive to these situations, we observed them proactively supporting people in a kind and caring way, in line with their care plans, to de-escalate anxieties and reduce the risks to people.

People were supported to manage risk while maintaining independence and the service promoted positive risk taking. The registered manager described a situation where they had collaborated with a person, their relative and healthcare professionals to ensure the least restrictive action was taken to support the person safely to go out.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The provider had identified night staff had not been involved in fire drills since November 2025 and had plans in place for night staff to start participating in the new schedule for fire drills, which had recently commenced. A programme of internal redecoration and refurbishment was underway for the building; a range of upgrades had already been completed.

Health and safety and fire safety risk assessments were completed and checks made of equipment to ensure it was safe to use. Any concerns with equipment were reported to the management team or appropriate person for further action.
 

The provider made sure there were enough qualified, and experienced staff. They made sure staff received effective support, supervision and development.

However, staff recruitment records did not always show all appropriate checks or the decisions the provider told us they had made to ensure only appropriate staff were recruited. We spoke with the registered manager about this who assured us processes were being put in place to make these improvements and to mitigate risks.

Training monitoring records evidenced staff had completed their statutory and mandatory training and competency assessments to ensure they were able to meet people's individual needs. Staff had attended additional training relevant to people’s individual needs.

The provider did not always assess or manage the risk of infection. However, when identified, they shared concerns with appropriate agencies promptly.

Staff had access to sufficient quantities of cleaning materials and personal protective equipment. We reviewed cleaning schedules which were consistently completed. People and their relatives told us the home was clean, and we observed this.

However, we did observe trolley’s containing unsecure used clinical waste bags being left outside people’s bedrooms where cleaning was taking place. We observed a person opening the lid of the clinical waste bags. We spoke with the registered manager about this who told us this went against their policy. The registered manager immediately put plans in place to mitigate the risk of this occurring again.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

However, the administration of emollient creams was carried out by care staff. Only nurses had access to the online medicines recording system. Staff told us they recorded the administration of these emollient creams in people’s daily notes. We reviewed daily notes and found minimal recording of applied creams which did not identify the name of the cream applied or where it was applied. There was good communication between nurses and care staff each shift to confirm staff had applied creams however, this was not documented. This increased the risk of creams being not applied or being applied more than once. The registered manager told us they were aware of this and were reintroducing topical medicines administration records to ensure these were recorded accurately.

Daily records did not always demonstrate blood glucose monitoring was carried out regularly in line with people’s care plans to inform medicine decisions. The registered manager told us they were assured this was a recording issue as blood sugars were discussed regularly in daily meetings and records confirmed this.