Chesford Grange Care 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 requires improvement. At this assessment the rating has remained 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 people’s safe care and treatment and safeguarding people against unlawful restriction

This service scored 41 (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, and they did not always investigate and report safety events. One relative told us about their family member experiencing a fall. They told us they were unsure what actions had been taken to lower the risk of this recurring. We requested the incident form to review actions taken. However, there was not an incident form available. The provider shared their actions, including seeking medical advice following the fall. However, without clear incident analysis the provider could not be assured the incident was fully investigated and mitigation action taken to reduce the risk of recurrence.

Lessons were not always learnt to continually identify and embed good practice. During the last inspection, we found concerns relating to risk management, escalation of incidents, safe handling of medicines and overall governance. During this inspection we continued to find concerns within these areas.

People told us they felt safe living in the home with the staff who supported them. One person said, “The staff are brilliant, they really are good. The staff are always there for you when you need them.” However, one relative told us when they raised a concern this was not dealt with promptly.

Staff told us incidents and accidents were shared in team meetings and through the provider’s electronic recording system. One staff member told us, “We can read about incidents or accidents on the handheld devices. We [staff] find out what has happened and read about new changes.”

The provider did not manage or monitor people’s safety effectively. People’s oral health was not managed safely. There were no records available to show how staff supported people to manage their oral hygiene or whether people had declined this support. This put people at risk from poor oral care. Where people experienced health conditions such as diabetes, their condition was not managed safely. Where clinical staff were required to take readings of blood glucose twice a day, readings were not always taken, there was no rationale or explanation recorded to explain why the reading had not been recorded. Where people required staff to monitor their weight, this was not always completed safely. We spoke with clinical staff over a discrepancy with 1 person’s weight as they had experienced rapid weight gain. Clinical staff told us some staff did not always use the weighing scales correctly. However, this had not been followed up with the provider.

The provider failed to ensure airflow mattresses were set according to people’s weights. Settings of mattresses were not recorded in people’s care plans; therefore, the provider could not be assured staff had the knowledge to check the mattress settings each day.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. One person with a diagnosis of diabetes was seen by a health professional who advised an increase in the person’s blood glucose readings. However, the provider failed to follow their advice.

However, despite these concerns people told us they were happy living in the home and staff told us they worked as a team to support people safely.

The new manager started their employment during this assessment. They were proactive to all of our feedback and put in new systems and processes to improve the overall monitoring of people’s safe care and treatment. We will review the success of these new systems during the next assessment.

The provider did not work well with people and healthcare partners to protect people’s right to live in safety, free of avoidable restriction. During the first site visit, 1 person, who was in bed, indicated to us they wanted to get up. When we spoke with staff, they informed us the person often disrupts others in communal rooms, which was why they remained in bed or in their bedroom. There were no best interest decisions available in place to support this decision. We raised a safeguarding concern with the local authority on behalf of this person.

Where restrictions were in place such as people requiring covert medicines or the use of bed rails, mental capacity assessments and best interest decisions had not taken

place.

During the second site visit, 1 person was in bed. When we asked staff why the service user was still in bed to ascertain whether this was their choice. Staff informed us their sling was in the laundry. No spare sling was available to support the person out of bed. This meant should the person indicate they wished to leave their bed they would be restricted due to the lack of equipment in the home.

Where some service users lacked mental capacity over certain decisions, Deprivation of Liberty Safeguards (DoLS) authorisations had been submitted. However, some of these were out of date and had not been followed up in a timely manner.

However, people told us they felt safe living in the home, and staff told us how they would raise safeguarding concerns with the management team. The new manager started in their role during this assessment, they were proactive to all of our feedback. They introduced new systems and processes to improve the overall monitoring of Mental Capacity assessments and best interest decisions, and they removed restrictions placed on people without authorisation. We will review the success of these new systems during the next assessment.

The provider did not always ensure risk assessments were reflective of people’s current needs and abilities. For example, where one person was assessed as being independent when eating their meals, we observed staff supporting this person to eat.

Staff did not always provide care to meet people’s needs that was supportive and enabled people to do the things that mattered to them. People were not always encouraged to make their own choices. For example, during a mealtime observation, people were not asked where they wanted to sit, and people were not asked if they wanted support to join others in the communal lounges or dining rooms.

Some people’s bedroom doors were locked whilst they were in communal rooms. Staff told us this was carried out to prevent other people from entering their bedroom. However, should the person choose to return to their bedroom they would be unable to do so without assistance from staff. There were no records of people being involved in this decision or best interest decisions being made.

Despite these concerns people told us staff encouraged them to be independent and to take risks. One person said, “I do most things myself. I’m even walking a bit more independently since being in here."

We observed staff responding to people who experienced distressed emotions, staff remained calm and supported people positively, whilst promoting choices.



The new manager was responsive to all of our feedback, they introduced new auditing systems of care plans and risk assessments and increased observations of care practices. We will review the success of these systems in the next assessment.

The provider did not detect and control potential risks in the care environment. Internal health and safety checks such as water temperature checks and fire safety checks were not carried out throughout November and December 2024. Failure to notice the absence of these checks over a prolonged period placed people at risk of harm from living in an unsafe environment.

Relatives told us the home was clean, and people’s bedrooms were well maintained.

We spoke to maintenance staff who shared their plans to ensure all internal health and safety checks were completed.

External health and safety checks had been carried out by visiting professionals and the home was compliant with building regulations.

The provider did not always make sure there were enough qualified, skilled and experienced staff. Where people experienced health conditions such as diabetes or epilepsy staff had not received training in these conditions. However, signs and symptoms of these conditions were described in people’s care plans.

Most staff had received their mandatory training. However, 4 staff had not completed their moving and handling practical training. The manager responded to our feedback by ensuring the identified staff completed their training during this assessment.

The provider used a dependency tool to calculate the numbers of staff and type of staff needed to support people safely. However, there were days when the number of clinical staff fell below expected levels. The new manager introduced new systems to have more oversight of staff rotas.

People told us staff supported them safely. One person said, “The staff are out of this world, there is nothing they won’t do for you. They are brilliant. I can’t wish for anything better." Another person told us, "The staff are all very lovely sociable people. I do think there’s enough of them, although they are always very busy. They turn up in no time at all to answer my call bell. They always have a smile on their face, I couldn’t wish for a better bunch."

Staff told us there were generally enough staff on duty to support people safely. Although they said they struggled during busy times, especially around mealtimes. The new manager introduced new systems to alleviate pressure during busy times. We will review the success of these new systems in the next inspection.

Staff were recruited safely. Recruitment files showed all pre-employment checks had been made to ensure only staff who were suitable to work with people were employed.

The provider did not always assess or manage the risk of infection. On the first day of the site visit, one person’s pressure cushion seat was soiled, the person was in bed waiting to be supported with breakfast. This meant the cushion had not been recently used and had not been checked. On the second site visit, we checked and confirmed the cushion was clean. However, when checking the person’s sling we noted this was hanging up and was soiled. In addition, we raised concerns over 3 people’s fingernails, these were long and dirty and there were no records indicating whether nailcare had been attempted. These concerns placed people at increased risk of infection.

The home was generally clean and smelt pleasant. However, some areas were tired and would benefit from refurbishment. People told us they lived in a clean environment. One relative said, “The home is clean. Staff are regularly cleaning [my family member’s] bedroom.”

Staff told us they had a cleaning schedule they had to complete each day which was checked on a weekly basis.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Some people needed their medicines administered covertly. Covert medication is when medicine is given to someone without their knowledge or consent, such as hiding the medicine in food or drink. However, staff told us this was not always carried out safely, and staff said the clinical staff did not check the food (which contained covert medication) was consumed. This meant the provider could not be assured people were receiving their medicine safely. We raised a safeguard with the local authority safeguarding team about this practice and the new manager investigated this concern. The new manager was open and honest in their investigation and found improvements were needed to ensure people received their covert medicines safely. They implemented new processes which we will check in the next assessment.

Where people required medication via prescribed skin cream. This was not being recorded safely. There were numerous gaps on medication administration records without clear explanation. This placed people at risk of harm from unsafe medication practices.

We undertook an observation of medication administration, and we saw that people received medication in a safe way during our site visit. People told us they were happy with the way they received their medicines. One person said, “The staff check my blood pressure often and bring me my tablets. Staff have never forgotten.” Another person said, “Staff bring me my tablets every day at the time I have to take them.” However, a relative raised concerns about staff not watching people take their medicines. We shared this concern with the new manager who carried out an investigation.

The provider was responsive to all our feedback. New systems and processes were introduced when administering covert medicines and recording skin cream. We will review the success of these in the next assessment.