Charnley House

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Governance arrangements weren’t fully effective. Whilst some of the concerns we found during the assessment had been identified through audits, appropriate action had not been taken to ensure they didn’t happen again.

This service scored 68 (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 sought the views and opinions of staff to drive improvements. The provider was mindful of the importance of a good culture within the service. Staff explained how they linked in well with people’s relatives and supported them as well as the people using the service.

Staff told us they were aware of the people who did not have the finances to buy their own clothes and with the permission of the person, or relative, would often purchase items for them. Staff told us they felt well supported, and there was a good culture within the home. The activities coordinator explained how, following our last inspection, they had increased their working hours to allow more time to better coordinate activities for people.

They said there was now a timetable of activities for the week, and people recently attended a pantomime, and had been on a boat trip in Stockport; which contributed to social inclusion. One-to-one conversations with people were completed. A hairdressing service was available once a month as well as holistic therapy; the holistic therapist has helped staff to get a better understanding of people’s stress levels who were unable to communicate this for themselves.

In order to gain wider feedback on how the home was operating, the provider had sent a survey to 60 stakeholders, with 16 responses received. Questions asked included the usefulness of the service user guide, the usefulness of policies and procedures, professionals involvement in people’s care plans, access to healthcare, levels of privacy, involvement in activities and the overall atmosphere of care provision which in itself had achieved an 81% good response rating.

The registered manager followed an ‘open door’ policy and people, relatives and professionals were welcome to meet the registered manager and provide feedback at any time. A registered managers ‘surgery’ was held each month and people could book slots in advance.

All staff members were very helpful, welcoming and very friendly and there was a calm and friendly atmosphere around the whole home in all rooms. All staff appeared to know people well and spoke to them using their first names; there was laughter and banter between staff and people throughout our site visit.

We saw several examples where staff were supporting some people to move around the home which was carried out in a dignified, safe and caring manner. We asked how people’s cultural needs were identified and acted upon, and staff gave an example where one person who had a strong faith and would say [name of prayer]; staff were aware not to interrupt this person whilst completing the prayer and staff had also been involved with a local church to arrange communion for the person which they had received in the previous month.

There was a clear management structure in place and staff understood their individual roles and responsibilities. Relatives told us they found management to be open, responsive and led the service well. Staff reported the service was well-led, with management being approachable. A person told us, “I feel safe and looked after. Its lovely here I can't speak highly enough of the place. I have everything I need here. My room is cleaned regularly, and staff wash my clothes regularly and put them back in the wardrobe for me. The staff are very good, and they look after me well. I can please myself what I do and when I get up and go to bed. There always seems to be enough staff about to care for our needs. I sometimes go out with one of the carers or I have two carers who come in and take me out into town. I am very happy here.”

Staff told us they felt able to raise concerns and that they would be listened to. One staff member stated, “Most staff get on well together and management are extremely friendly, approachable and supportive. I have no concerns with raising issues and I feel they would be resolved.”

The provider had an up to date Raising Concerns, Freedom to Speak Up and Whistleblowing policy in place which had last been reviewed in September 2024. Staff confirmed they had read and understood this policy. There were mechanisms in place for staff to speak up and a culture in place to encourage them to do so. Good communication was in place through the night time senior staff on-call system, team meetings and formal 1-1 sessions to ensure staff had regular opportunities to engage with senior leaders. This was also supported by policies and information which enabled staff to raise concerns externally if required.

Staff and leaders were representative of the local population. Staff told us they felt valued by the provider and worked well as a team and enjoyed working at the location. Throughout our on-site visit we saw there was a respectful and pleasant culture amongst staff and leaders. One staff member told us, “I feel the culture here is excellent and I feel heavily supported by the registered manager.”

There were policies and procedures in place to support non-discriminatory and equitable staff recruitment. Processes were in place to support staff to carry out their roles to the best of their ability.

The registered manager told us about improvements made since our last inspection. This included changing the names of the units, which were decided by people and relatives at a meeting and changed. There was now a notice board for all scheduled activities and a relatives notice board. Changes had made to where the dining room was located, and changes made to the conservatory.

Changes had been made to one toilet on the middle floor and carpets were being replaced in bedrooms when needed. Staff now used hand-held pictorial cards to assist people in choosing things such as a drink or something to eat. There were now more external activities. A new pictorial menu was on display. Handrails in the corridors had been changed to a pink colour which made them more visible to people who may be disoriented due to living with dementia.

There was evidence of quality assurance checks and monitoring of the service being undertaken by the registered manager to measure the quality of care delivered to people, however, these had not identified and rectified the issues we found during our site visit. We noted some of the concerns had been identified earlier in 2024, for example poor record keeping, although this had not been fully addressed at the time of the inspection. The completion of records/monitoring charts and other areas of risk management had also been an area of concern at our last inspection in 2023.

Meetings were held with people using the service and their relatives, which were now more frequent and regular. We saw the provider had discussed our previous inspection report with people and relatives and the suggestion for a relative’s notice board had been implemented. An annual home maintenance action plan was in place, and this included a monthly update with any findings from environmental checks made within the month.

Planned works included replacing flooring, refurbishing toilets and general redecoration. The existence of this plan also provided an opportunity for managers to identify how to create a more dementia friendly environment.

A servicing schedule identified when equipment needed re-servicing, including hoists, the lift, the fire alarm system and utility supplies. The provider completed staff spot checks, which were used to ensure staff were carrying out care and support as necessary and all required tasks had been completed. A dependency tool was used to calculate how many staff were required to safely support people. There was a business continuity plan in place in the event of an unexpected occurrence, for example loss of non-residential areas, loss of utilities and catering disruption. We observed one radiator without a cover on, although we were informed by the registered manager this had been removed by a person living at the home and the radiator was not hot.

There was a weekly time table of events on display in the corridor. During our site visit, the hairdresser attended in the morning. An annual barge trip had taken place in September 2024 and a visit to the theatre had been planned for December 2024. Meetings with people’s relatives took place every few months and people told us they had separate residents meetings. Most people said they were able to please themselves and do as they wished but several people told us they would like to go out more. People and relatives spoke positively about the care provided. One person said, “I have been to the theatre and on a boat trip with the activities lady.”

Staff worked in partnership with people’s relatives to help meet their assessed needs. We were provided with written feedback received from the relative of a person who had recently passed away; the feedback stated, “I am writing to express my heartfelt gratitude for the exceptional care and compassion the whole team provided for [person]. All the staff at Charnley House went above and beyond in looking after [person] and they also looked after me very well too. Your efforts made a significant difference to [person’s] quality of life in these final years.” All people and relatives we spoke with said they were all aware of the management team and they would be very happy to raise any concerns or issues they may have; they felt they were listened to, and any issues were acted upon and addressed.

The provider worked alongside partner agencies to help meet people’s care needs. The number of staff hours dedicated to activities had increased since our last inspection and activity support included the provision of activities from outside people, for example, entertainers and a holistic therapist. There was evidence, in people’s care plans and daily notes, the provider had liaised with various health professionals to ensure safe care and treatment for people living at the home. The activity coordinator explained how they had a good understanding of people’s individual needs and tailored their approach to meet these needs. They activity coordinator gave an example of a person who was ‘shy’ and instead of attempting to force them to be involved with activities, the activity coordinator had spent time with them on their own, getting to know them; as a result of building up trust, the person had started growing in confidence and now took part in activities with other people.

We did not receive any feedback from partners regarding this evidence category.

There was evidence in the care plans and daily notes the provider had liaised with various health professionals to ensure safe care and treatment for people living at the home. Staff and leaders understood their responsibilities to work in partnership with external care professionals to ensure people received joined up care. Referral procedures were in place to ensure people received support from health care partners, such as district nurses and chiropodists.

The provider had implemented a number of improvements since our last inspection as reported earlier in this report. Improvements had been made to the environment, staff now received more regular supervision and training, and people and relatives now had more opportunities to be involved in making suggestions for improvement. Staff were encouraged to speak up with ideas for improvement and innovation. One staff member told us, “Complaints are shared with the staff involved, but I’m unsure whether they would be shared with the whole team, as there are so few formal complaints.” We saw staff direct observation sheets, completed by managers, included a check on if the staff member knew what to do with a complaint and where complaints were kept. Another staff member felt how training was delivered could be improved; they told us, "I feel training could be better. Often training modules are online and I feel I would benefit from more face to face training.

There was now a better process of monitoring and auditing in place to ensure continuous improvement. However, processes to ensure continuous learning, improvement and innovation were not fully developed and needed better embedding into day-to-day practice to ensure the concerns identified during this assessment were fully addressed.