Chase House Limited

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.There was an increased risk that people could be harmed. The service was in breach of legal regulations related to safeguarding and safe care. Safeguarding concerns were not always identified and reported. Incidents were not always well documented or managed. Care plans did not always contain enough information on managing risks. Medicines were not always managed safely. Environmental safety and infection prevention and control risks had not always been managed.

This service scored 31 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always have a proactive and positive culture of safety based on openness and honesty. Staff had not always appropriately recorded incidents, such as when people experienced emotional distress appropriately. This meant the service could not investigate or report all safety events. This placed people at increased risk of harm.

The service did not always maintain safe systems of care to manage risks people could experience or be exposed to. Safeguarding concerns were not always identified, health risks to people were not always well managed, and care plans did not always reflect people’s needs. However, the service worked with healthcare partners when they had identified concerns such as people experiencing ill or deteriorating health. For example, we observed staff sharing information about their well-being, presentation and prescribed medicines during weekly GP ward rounds.

People were not always protected from abuse and improper treatment. The provider had failed to identify and report all safeguarding concerns to the Local Authority safeguarding team. Due to this, people and relatives had not always been informed of concerns such as altercations between people. Not all staff we spoke with could tell us who they could report safeguarding concerns to externally if they needed to. Failing to recognise potential safeguarding concerns and staff not always knowing how to escalate concerns externally placed people at increased risk of harm.

The service did not always plan care to meet people’s needs safely. People were at increased risk of avoidable harm as the provider had failed to always fully assess or evidence they had mitigated known risks, such as risks relating to emotional distress, people’s mobility and health-related conditions. We observed on three occasions people being supported to mobilise unsafely with mobility equipment. However, relatives we spoke with felt appropriate action was taken in response to risks people could experience. A relative said, “[Person] did have a fall once when [Person] tried to get out of bed; that was 6 months ago. [Person] was checked over, and they put an alarm mat by [Person’s] bed. Now [Person] has the (bedrails) up.”

The service did not always detect and control potential risks in the care environment. We identified 2 taps in communal areas being able to get hot enough to scald, unsafe storage of cleaning products, window restrictors with incorrect fittings, missing equipment on fire exits, excessive gaps in fire doors and wardrobes not being secured to bedroom walls where people were at known risk of experiencing falls. We found the service did not have a robust fire risk assessment and their legionella risk assessment was not in date.

People, relatives, and staff expressed concerns about being short-staffed during unexpected staff absences. A staff member said there were not enough nurses during the day, which left little time for them to interact with people. One person told us they could wait long periods after ringing the bell for support and that staff did not have much time to talk with them. In response to staff feedback, the registered manager said they had assessed planned staffing levels as appropriate, and management provided care during staff shortages. Improvements were needed to recruitment processes, such as asking structured and relevant interview questions, checking the applicant's work history and ensuring robust reference checks. Staff training in safeguarding, medicines, and supporting people with their mobility had not led to staff providing safe care in these areas. However, staff told us they received regular supervision and team meetings.

The poor upkeep of areas such as seating, bed bumpers, and pressure relieving equipment did not promote effective cleaning of those items. However, at the time of our assessment, the service was experiencing an outbreak of acute respiratory illness, and we observed that staff used PPE appropriately, signage was in place, and visitors were supported to use PPE. A relative told us, “Laundry and hygiene are very good. It’s the cleanest home [Person] has been in.”

The service did not make sure that medicines and treatments were safe. We identified concerns with the safe storage of topical medicines, including people having expired medicines and finding medicines in people’s rooms and communal areas belonging to people who had passed away. Protocols for medicines used on an ‘as required’ (PRN) basis were not always in place or did not contain enough person-centred information. We found that the physical stock of people’s medicine did not correlate with what the service had recorded on their electronic medicines administration system, this increased the risk of medicines errors not being identified so appropriate medical advice could be sought. There was increased health risks to people from not receiving their medicines safely.