Archived: Kettlewell House Nursing Home

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 changed to inadequate. This meant people were not safe and were at risk of avoidable harm.The service was in breach of legal regulation in relation to safe care and treatment, safeguarding, safe and effective staffing, recruitment and duty of candour.
 

This service scored 34 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Leaders and staff did not record incidents and accidents consistently. This contributed to lack of investigation to understand how people had been placed at risk of harm, and any learning to mitigate future risks to people. We found repeated incidents of staff raising concerns of physical abuse towards people. We found not all these allegations were recorded in the provider’s incident log. This meant prompt action was not taken to minimise the risk of the concerns happening again. The provider did not ensure there was a consistent process in place for recording and reviewing accidents and incidents and sharing any learning with staff. Therefore, the provider did not ensure all risks were mitigated and care plans were updated to reflect any changes in people’s individual needs.

The interim manager told us they were not made aware of the numerous allegations of abuse towards people when they joined the service, and they were unaware of staff dismissals as a result. The interim manager confirmed they became aware of this information during the CQC visit. This meant there was a clear lack of transparency within the service, and this meant the interim manager’s ability to monitor and manage all known risks to people was ineffective.

The provider confirmed one identified learning outcome following the numerous allegations of abuse was for all staff to repeat their safeguarding training. However, we reviewed the staff training matrix and found not all staff had repeated this training. The provider’s failure to ensure up to date, effective learning and competency around this meant people were at continued risk of ongoing harm and abuse. The provider’s safeguarding audit showed not all staff had read the safeguarding policy, despite this action being overdue from June 2025, and following several serious allegations of abuse.
The provider failed to evidence people and their relatives were all kept up to date with any concerns or outcomes, including when serious notifiable incidents occurred.
 

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.
We received mixed feedback from people and staff. One person told us, “The referral process was amazing.” However, another person told us, “The nurses come round and the top people say, we’ll do that and do that, and I bet you can guess, it doesn’t happen. I’m still waiting, and I’ve gone on and on and on.”
One staff told us, “I don’t know people’s needs anymore unless they tell me.” This did not demonstrate a continuity of care for people, and a robust system and process was in place to ensure people’s needs were understood by staff and recognised when they changed.
 

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.
We identified investigation reports conducted between the interim manager and several staff, where staff raised serious allegations of physical and psychological incidents of abuse of people from staff. These incidents included people’s hair being pulled, rough manual handling, a person being sworn at, a person’s foot being stood on and multiple concerns of physical abuse during provision of personal care. We found some staff were dismissed following this investigation.
Staff had received safeguarding training but failed to demonstrate they understood how to put their training into practice. We found examples where staff had failed to recognise safeguarding concerns and had not taken appropriate action such as reporting these concerns to relevant external agencies. This meant some incidents had not been effectively investigated, and action taken to keep people safe. The provider had not reported all safeguarding concerns to CQC and the local authority without delay. These delays and omissions raised serious concerns about the provider’s compliance with safeguarding requirements and their duty to notify relevant authorities promptly.
 

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.
We found Personal Emergency Evacuation Plans (PEEPs) were not regularly reviewed, updated and in place for all people. This meant people were at ongoing risk of significant harm in case of an emergency evacuation. We raised this concern with the provider at the time of our visit. However, this demonstrated some risks were only addressed when raised by inspectors and not proactively identified and resolved by the provider.
We identified 1 person with epilepsy, and 1 additional person experienced seizures recently. However, the clinical lead confirmed staff had not received training for emergency medicine for epilepsy, despite a care plan stating people may require emergency administration of medicine for epilepsy . However, the clinical lead dismissed epilepsy training as ‘lower priority than diabetes’. We asked the provider how they were assured staff were competent to meet the specific needs of people with epilepsy and rescue medicines. We were not assured mitigating strategies or effective training were in place. Not all staff knew there were people with epilepsy within the service.
We also identified staff had noted they ‘restrained’ 1 person. The provider was not aware of this prior to inspector’s feedback. Furthermore, this was recorded on ABC charts, not incident forms or logs. An ABC chart is a tool for analysing behaviour, recording Antecedents (what happened just before), Behaviour (the behaviour itself), and Consequences (what happened immediately after). This tool helps to identify triggers, understand the behaviour, and find patterns to inform strategies for managing and supporting positive behaviour. However, the provider failed to identify people were at risk of experiencing ongoing abuse and harm. This meant themes, trends and known risks to people were inadequately monitored to ensure people did not experience the harm and abuse. We raised these concerns with the provider. However, the leadership team dismissed this as a language barrier issue, and not having witnessed this restraint themselves, added they “don’t think [staff] mean it.” The leadership team failed to demonstrate they understood the seriousness of these concerns and ensure unsafe practices could not continue unchecked. There were serious concerns regarding the provider’s failure to demonstrate they effectively investigated these concerns and addressed root causes prior to dismissing potential abuse.
 

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

We found the environment of the service did not always support people who are most likely to experience inequality in experience or outcomes. The home environment was not fully adapted to the needs of people living with dementia. This did not ensure people were supported in line with nationally recognised best practice guidance on environments supporting people living with dementia. For example, we found the toilet seats and taps were not all distinctive in colour and easily recognisable. We also found the service did not support people with individual memory boxes, which are designed to be used to help people remember the past. They can help support people with communication and their unique backgrounds. Around the service we observed generic pictures were displayed on the walls. However, there was no differentiation in colour or texture and no signage to aid those people living with dementia. Some signage was place up high on walls for people to refer to.

We noted large display clocks were not accessible in every lounge and dining room, and we did not observe clear and distinctive signage to all toilets in the corridors. This meant people’s care was not always tailored in response to their needs. These elements of the environment did not ensure people with dementia were supported to experience better outcomes.
 

The provider did not 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 work together well to provide safe care that met people’s individual needs.

The provider did not operate effective and robust recruitment procedures to ensure they employed suitable staff, in line with Schedule 3 and their own policy. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Schedule 3, mandates that providers must keep specific information on staff, including employment history and conduct evidence. We found discrepancies with gathering information of full employment history including gathering evidence from previous employments related to health and social care regarding staffs conduct and verifying the reasons for leaving. We asked the provider for further evidence on the missing information, including evidence the adult barred list was checked; however, this was not all provided. By failing to obtain all required recruitment information before staff started work, the provider put people at risk of being supported by unsuitable staff.
Staff were not receiving regular supervision and support. The provider’s records evidenced out of 60 staff, only 24 had received a supervision in 2025. This meant an increased risk of training, support and development needs being unmet. Following whistleblowing concerns of abuse raised during a supervision, the provider failed to demonstrate learning had been taken from this to ensure supervisions were implemented more frequently to address the risk of a closed culture.
We requested evidence of ‘train the trainer’ certificates for the staff who were providing in house training and competency assessments for topics such as manual handling, medicines administration and diabetes. The provider did not evidence the clinical lead and deputy manager had received train the trainer certificates and were assessed to complete competency assessments prior to delivering and assessing other staff on these topics. This meant the provider put people at risk of being supported by unsuitable staff.
 

The provider did not consistently assess or manage the risk of infection. Risks were not always identified, controlled, or communicated to relevant agencies in a timely manner.
During the inspection, malodour was noted in some areas of the home. This had also been recorded in the provider’s own infection prevention and control audit.
One relative reported: “There was a norovirus outbreak, and we were left off the email list.” This feedback indicated that systems and processes in place did not always ensure that information about infection risks was shared appropriately with people using the service and their visitors.
 

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.

We found there was a lack of clinical oversight of people’s medicines. For example, we found 2 bottles of liquid paracetamol on site which should have been discarded due to being open for over 2 months. Also, in some people’s medicines boxes we found bottles with tablets inside which did not have a clear prescription and direction of administration on them. The prescription label contained no information regarding the dose inside, or the checked or dispensed date. No assurance was provided how this medicine was safely managed and how oversight of this medicine was maintained. For example, the provider was unable to demonstrate safe systems and processes were in place to monitor expiry and stock count for this medicine.
Furthermore, in one clinical room where medicines were stored, the temperature was too high for the safe storage of medicines. The provider confirmed an air conditioning machine had been ordered but would take a few days. We also observed records which evidenced the temperature of this room exceeded 25 degrees 9 times within 3 months. The provider failed to demonstrate the ongoing risk to people’s medicines and oversight of safety was already being managed before, and systems and processes were already in place to mitigate this risk. The provider did not evidence they assessed the impact of this risk on people’s medicines, as best practice guidance advises clinical room temperature should not exceed 25 degrees. We found the provider’s medicines audit confirmed the interim manager was informed regarding the need for air conditioning in the pharmacy room in the June 2025 audit. Despite this, the risk was not mitigated, and this request was not actioned. This meant there was poor medicines governance, and people were at risk of avoidable harm and risk of receiving ineffective treatment.
The provider’s audits failed to identify the concerns we found during our visit. For example, the medicines audit was showing the service was 100% compliant, despite the issues we found with oversight and management of medicines. This meant the quality assurance systems and processes in place failed to recognise and action risks to people’s safe care and treatment.