Chalgrove Care and 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 requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

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.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The registered manager and team had established improvements in the service since our last inspection. There was evidence of reflection following adverse events with clear timescales set for any identified action to prevent recurrence. Staff confidently explained the actions they took following incidents to reduce the risk of harm to people.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

People’s support needs were detailed within their care plans and risk assessments on the electronic system. An emergency pack was available if people went into hospital or moved to another care home, this supported continuity of care for people.

We invited health and social care professionals to share feedback of their experience supporting people who resided at Chalgrove Care and Nursing Home. Without exception, they told us of positive interactions with the staff team. For example, “Staff are always prompt with replying to correspondence and are happy to speak to us.”
 

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

People told inspectors what being safe meant to them and knew who to report concerns to if they did not feel safe. A person commented, “There is always someone here if something bad were to happen. I can speak to the registered manager. I'm very grateful to be here with the nurses keeping me safe. If I have any problems I can talk to the nurse or the registered manager.”

Staff were confident all concerns would be investigated by the registered manager and the provider. Staff knew of external agencies such as the police and local authority safeguarding team who they could contact in the event the concerns were not acted upon. A staff member informed us, “I have not had to raise a safeguarding concern to the registered manager or the safeguarding team, and I take pride in this as it proves that the home is running well.”

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA, whether appropriate legal authorisations were in place when needed to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met.
The registered manager had oversight of these applications, authorisations, and conditions. This meant people’s rights were fully respected.
 

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People told us, “I can be independent here, but there are staff around if I have a fall” and, “I am much safer now, I have the right equipment and can press this bell whenever I need help. Oh yes, the nurses always come along quickly.”

Staff told us about daily tasks completed to keep people safe. These included daily safety checks of the environment and reporting any concerns to the maintenance team so these could be repaired.

Processes in place ensured the risk of harm to people was fully assessed. As part of a pre-assessment before moving to Chalgrove Care and Nursing Home, risks to people’s health and wellbeing were identified with planned outcomes agreed to reduce the risk to the person clearly outlined in their new care plan.
 

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The registered manager understood and followed the service’s health and safety procedures. Health and safety audits took place regularly and any areas for action were addressed. Checks of the environment and equipment were undertaken in line with the provider’s policy and legal requirements.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

People and their relatives told us they were enough staff on duty who knew how to provide their care in a person-centred way. A relative stated, “The staff and management are caring, friendly and professional.” Another relative told us, “The care and attitude of the staff we encounter is always really good. They are very dedicated and patient.”

The provider had effective processes in place to ensure staff had the necessary skills and competence to carry out their roles. Recruitment records showed staff were recruited safely. This included an enhanced Disclosure and Barring Service (DBS) checks for adults. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.
 

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

We observed the environment to be clean and free of unpleasant odours. Throughout the day we saw cleaning tasks in progress and recorded on the service’s action plan for planned improvement works .

A visiting health and social care professional fed back their observations of the person’s bedroom as, “Calm, clean, and very comfortable.”
 

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

The provider had a medicines policy in place. Medicines incidents or errors were reported and investigated. Medicines were ordered, stored, and disposed of securely. Stock of medicines were effectively managed, with staff taking pride in the improvements to the systems in place for medicines since the previous inspection. One staff member told us, “There has been lots of training, all nurses attend. We learnt so much covering medical conditions like diabetes, tissue viability, and ulcer care. The recent training in end-of-life care had us thinking about how we can review our end-of-life care plans so we can ensure people’s wishes are known and most importantly there is an advanced plan in place for end-of life medicines so they can be pain free.”