Charnley House

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

People said their needs and preferences were taken in to account and they were involved in planning and making decisions about their own or loved one’s care and treatment which was in line with their needs and preferences.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People told us their needs and preferences were taken in to account. Relatives said they were involved in planning and making decisions about people’s care and treatment which was in line with their needs and preferences.

Staff were aware of people’s care plans and told us they were regularly reviewed by senior members of the team or when a notable change had occurred.

Staff understood people’s conditions and made reasonable adjustments where necessary. For example, one person with a strong faith was supported with visits to the church and by arranging meetings with the local priest who attended the care home to visit them.

Staff explained how outings with residents had improved, including trips to a local school to watch a play which they performed and meals out at local restaurants. The activities coordinator had recently supported one person to attend a funeral of a loved one as this was important to them and their family.

We observed positive interactions between staff and people with specific needs, including a person with hearing difficulties. We saw staff understood their needs and provided appropriate care and treatment.

We observed person centred care plans being adhered to. For example, we saw people wearing the appropriate footwear as documented within their care plan.

We observed an activities coordinator actively engaging with people in the dining room and lounge area.

We observed images and staff provided accounts of how people had attended a pantomime and a boat trip in the last 6 months. A poster in the reception showed how a singer had attended the home.

We observed a completed document for one person in which a number of questions had been asked to them or their relative, on their arrival. This had been completed by a senior member of staff and informed their care plan.

Care records showed person centred plans were in place that took account of people’s individual needs and preferences, such as how they wished to be communicated with.

People told us care was coordinated well and staff planned and delivered their care and treatment in a way that met their needs.

People told us monitoring was completed regularly by district nurses, the complex care nurse and any other professionals including the general practitioner (GP) or dieticians.

People provided a mixed response when discussing activities available. Some said they were happy with the amount of activities, whilst others did not feel there were enough activities and said people rarely went out in to the community.

Staff told us they received information they required to plan people’s care and treatment.

Staff said they worked closely with visiting health and social care professionals to ensure support met people’s needs.

Staff told us people were offered treatment such as chiropody, support from opticians and physiotherapy.

The district and critical care nurse told us they had meetings with the senior management team and senior staff when they attended the care home which enabled continuity of care.

Staff could access support from district nurses and had regular support from the GP surgeries.

Staff worked with professionals to ensure people’s care needs were attended to. There was a weekly ward round completed with a complex care nurse. District nurses attended the home 2 – 3 times a week. There was a dietician service available on a Monday from 9am – 3pm and speech and language therapy were available on demand. The home had access to a service which provided medical appointments when required.

People had access to a hairdresser and a holistic therapist who attended the care home once a month.

Each staff member was allocated 4 people which they were key workers for. Although all staff supported people, key workers provided continuity in care for that person. The service attempted to request the same agency staff to provide continuity of care for people.

Care plans included information from reviews which had been undertaken.

Facilities were appropriate for the services being delivered. The design and layout of the care home ensured wheelchair and disability access and was secure.

Since the previous assessment of the service, the activities coordinator had increased their hours to allow more time for people to be engaged in activities.

The activity coordinator ensured there was an activity schedule in place for people. We noted there was a record of activities they had engaged with, which included one to one interaction throughout the day.

Most people told us staff provided them with the necessary information about their care and treatment and answered any questions they had. However, one person’s relative told us they had never been offered to view the care plan and did not know they were entitled to view it.

Staff and senior staff had regular discussions with one another regarding people’s care needs.

Staff showed us examples of how information had been adapted, including the mail for people with impaired vision being in much larger text.

One staff member said people with communication difficulties were supported by staff who would use flashcards if appropriate.

Staff were aware of the communication care plans for each person and knew how to access these.

Staff told us they had received training in communication and record keeping. They said they could easily access information such as care records, policies and guidance relevant to their role.

The service had a care communication and information policy and procedure which outlined how to access information related to people’s health and wellbeing via their individual, person-centred care plan.

The service held meetings for people living at the home and relatives. At the last meeting, professionals such as the district nurse and critical care nurses had been invited and attended.

There were systems in the care home which enabled staff to provide information to people in different formats, including using pictorial cues.

Staff ensured there was a pictorial menu in the dining area.

Following a consultation with people, names were now on their bedroom doors, although we noted some were missing. There were also pictorial images on the doors for shared areas such as the lounge and kitchen which were dementia friendly.

People told us they would feel comfortable raising a complaint or a concern with the registered manager or other senior staff.

They were unaware of the specific procedure regarding how to make a complaint but were all confident the registered manager had an ‘open door policy’.

Staff told us they encouraged people to share any concerns or feedback they had to the senior members of staff.

Staff understood the complaints process, and all explained how they would signpost to the registered manager but if they were unavailable how they would make detailed notes of the concerns and share them at a more convenient time.

Managers explained how they reviewed complaints and compliments to aid learning and development.

The service had a complaints, suggestions and compliments policy and procedure which had been reviewed recently and updated appropriately.

Within the service user guide, which was located at the main reception, there was a section dedicated to people making a complaint or giving compliments. The guide clearly outlined how to make a complaint and the services commitment following a complaint being submitted. However, the guidance did need to be updated as it contained details of a previous registered manager.

There was a complaints file which contained details of the complaints received. There were 4 complaints documented in the file since 2021 which managers confirmed was correct. The complaints file contained a complaints log; however, this had not been completed. The deputy manager explained this had been introduced following complaints being investigated.

Managers investigated complaints and identified themes. Internal records showed the service had received 4 complaints between 2021 to 2024. We reviewed the investigations for these and found they were investigated appropriately and responded to in a timely manner.

The care home routinely engaged with people to gain feedback from them. This occurred through informal daily engagement and formally through participation in bi-annual meetings.

Complaints and compliments were discussed with staff within scheduled supervisions.

The deputy manager told us they had not received training specifically for managing complaints, despite being involved in the investigation process with the registered manager. The policy for complaints, suggestions and compliments stated staff would undertake training on how to manage complaints in line with their roles and responsibilities and refers to some complaints being delegated to a senior member of staff other than the registered manager.

People told us they received the care, support and medical support when they needed it.

Staff were confident in making appropriate referrals to any external professionals based on people’s needs.

Staff explained how care needs were regularly reviewed by senior staff.

There were no concerns in relation to equity in accessing treatment raised by professionals we spoke to.

There were systems in place to ensure people had access to external health and social care professionals, including out of hours or in an emergency.

Staff were trained in equality, diversity and inclusion training, which was mandatory, 80% of senior staff and 72% of caring staff were compliant with this training.

There were 3 vacancies available at the care home. At the time of our assessment, there was a respiratory outbreak and as a result, people were given the option to delay their admission to the home if they preferred.

People with a variety of needs and backgrounds were supported by the home. They told us they felt supported.

Staff told us people were treated equally and as individuals.

The managers of the service were aware of inequalities people could face. Although the service did not have any people from black, minority and ethnic groups, the managers emphasized what would need to be taken in to account if a resident was to be referred including their religion and culture.

The service had policies in place to ensure people were treated equally. There were opportunities for people to give feedback about care and support.

Within the services user guide it stated the care home had a zero-tolerance approach to all forms of discrimination and would take action when it was identified.

People discussed their preferences about their end-of-life care with staff when they wished to.

People receiving end of life care were comfortable and had the support they needed.

Staff explained how they supported people who were on the end-of-life pathway. They told us how they would follow the updated care plans and provide personal care when required. Staff told us they felt supported by managers to prioritise time with people at the end of their lives.

Staff felt well supported by the arrangements in place to support those people who were on end-of-life care.

Staff felt end-of-life care was managed sensitively.

The manager and deputy manager told us extra staff were provided to support people who were on end-of-life care pathways.

The service had an end-of-life care planning policy and procedure which had recently been reviewed and amended. The policy stated all staff needed to be competent and up to date in their knowledge and practice regarding end-of-life care.

However, we found not all staff were up to date with their training in palliative and end of life care. We found 40% (2 out of 5) of senior staff and 61% (11 out of 18) of caring staff were not up to date with their training. Therefore, we were not assured staff would be able to provide effective management of care for people who required end of life care. This was identified at the services previous inspection and had not been resolved.