Chestnut Lodge

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.

This is the first inspection for this newly registered service. This key question has been rated inadequate. The provider is in breach of a regulation in relation to safe care and treatment. Risks to people were not always safely managed. For example, risks in relation to weight loss and skin integrity. People were not always protected from abuse and avoidable harm and standards of care were not improved as a result of lessons learnt. Not everyone had the equipment they needed and where they did it was not always fit for purpose. Deployment of staff was ineffective, and people did not consistently have their needs met safely. People’s medicines were not managed safely. The service was mostly clean however, some aspects of infection control required further attention.

This service scored 34 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People did not give any negative feedback regarding the learning culture at the service. However, the processes in place did not support people to experience consistently good care. At times, the practices in place increased the risk of harm to people. Feedback from lessons learned was not always shared.

Managerial oversight of lessons learnt was limited. Where actions had been identified, there was insufficient monitoring of these which led to repeated errors occurring. For example, medicines stock counts and monitoring of people’s weight.

Systems and processes in place were ineffective in supporting a learning culture. Accidents and incidents were not always recorded and appropriately reported. Systems in place were not effective in identifying and sharing lessons learned to improve practice and mitigate future risks.

People we spoke to did not raise any concerns regarding their admission to the service or accessing health professionals when they needed. One relative told us, “[Name] see’s the chiropodist.” However, we identified incomplete pre-admission records. This meant people were at risk of not receiving appropriate support to meet their needs because staff did not have the information needed to deliver person-centred care.

Leaders and staff had not ensured that people’s preadmission assessments were in place and fully completed. However, staff knew how to make referrals to health professionals when needed.

Partners expressed concerns regarding the safety of people and the systems in place at the service. However, feedback from health professionals visiting the service was mostly positive. They felt the home worked well with them and followed their advice.

Systems and processes to support safe admissions were not effective. During this assessment we found some people had no pre-admission assessment in place and other people’s assessments contained significant gaps in information. For example, physical observations on admission and equipment needed. This meant staff lacked information and guidance to support people safely.

People told us they felt safe at the service. However, we found people were not always protected from abuse and avoidable harm. Where altercations had occurred between people living at the service, it was not always clear what actions had been taken to support the people involved and reduce the risk of reoccurrence, placing them at risk of harm.

Some staff told us they did not always have time to complete documentation in relation to peer altercations and submit reports. This meant there were missed opportunities to report any potential safeguarding concerns.

Staff and leaders did not always appropriately report safeguarding concerns. One staff member told us, “More training is needed for staff. Staff can struggle.” Other staff told us they had received safeguarding training and would know how to protect people from abuse.

Staff and leaders were not consistently responsive to protect people from avoidable harm. Some staff practices needed further improvement. People had experienced harm from other people, with some incidents going unreported. Equipment in place was used, though it was not necessarily safe for people.

Systems and processes were ineffective in protecting people from abuse and avoidable harm. Managerial oversight of safeguarding concerns was insufficient. For example, the registered manager had not appropriately investigated an incident and did not know whether it had been reported to the local authority safeguarding team. In addition, people’s care records were not updated when they had been the victim of assault, therefore staff lacked guidance regarding how to keep them safe. For example, 3 people had been victims of assault on separate occasions. For each of them it was not recorded in their care plan or risk assessment that this had happened, and there were no interventions in place to protect them from further risk of harm.

People were not involved in formulating or reviewing their risk assessments and care plans. This meant they were not involved in making decisions about potential risks and their safety. The systems in place did not encourage this practice.

Staff were not involving people to manage their risks and risk assessments were not completed collaboratively. Information within risk assessments did not support staff to care for people safely. One staff member told us, “We do not always know people’s needs, and some can be aggressive. We don’t have time to read care plans or risk assessments.” The registered manager had not maintained effective oversight of this.

Leaders and staff did not act appropriately to reduce risk. People used equipment which was unsafe or not assessed for them. This placed them at risk of injury.

Systems and processes failed to ensure risks to people’s health and safety were effectively assessed, monitored and mitigated. For example, risks associated with pressure damage, choking, weight monitoring and falls.

Care records contained conflicting, inaccurate and insufficient information which meant staff lacked guidance to support people safely. For example, 1 person, who smoked, used a paraffin based emollient cream on their whole body. This was a flammable cream and there was a risk of burns injury if their lit cigarette or lighter came into contact with their skin or clothing. However, this risk was not highlighted in their risk assessment, and no mitigation was in place to prevent such injury. In addition, 1 person’s malnutrition assessment stated they were both medium and low risk. Their body mass index was also below average however their care plan stated it was average. This meant staff did not have accurate information to provide the right support.

There were gaps in some people’s hourly safety checks and repositioning records, posing a risk to their safety. For example, repositioning charts for 1 person showed gaps of more than 3 hours, when they needed to be repositioned every 2 hours. This increased the risk of pressure damage to their skin.

Processes in place had not supported the involvement of people and relatives in the review of risks and care needs.

People did not always have equipment they needed and appropriate clothing to wear due to laundry issues. One person told us they had been unable to get out of bed for several days because their sling, used to assist them out of bed, had been in the wash and had not yet been returned. One person had to be covered up by a blanket as they had no clean clothes to wear due to a backlog of laundry. A second person told us they were unable to change into clean clothes because they did not have any available to them.

Staff told us people did not have their own individual wheelchairs. This placed people at risk of harm by using wheelchairs they had not been assessed for. Staff also confirmed that there were no spare slings available for people when they needed to be washed. In addition, 1 staff member told us, “People don’t have the right equipment, like sensor mats."

Equipment was not in adequate supply for people’s individual needs and was not maintained in safe and working condition. For example, we saw 3 wheelchairs that were damaged, only having 1 footplate. We observed 1 person being supported to use 1 of the wheelchairs. The inspector intervened to protect the person from harm. The registered manager was unable to locate any of the missing footplates or wheelchairs that were safe to use.

Not everyone had access to a call bell, and where in place, some did not work. Some people had sensor mats to sound an alarm to alert staff to their movements, such as a fall. We found 1 person’s sensor mat was not working on the second day of the assessment and we informed the deputy manager. Thirteen days later we found the sensor mat was still not working.

People’s walking frames were stored against the wall in the lounge, out of people’s reach. These were not individually identified, and staff did not know which frame belonged to which person.

During the third day of the assessment, we observed a large build-up of unwashed laundry in the laundry room, and one of the washing machines had broken. In addition, the bath seat on one unit was out of use on the first day of the assessment and remained unrepaired and out of use 20 days later.

Systems and processes were not effective in ensuring adequate checks were in place to maintain environmental safety and ensure equipment was available and in good working order. Oversight of these risks was lacking. For example, the registered manager was not aware 1 person had moved bedrooms, and their Personal Emergency Evacuation Plan (PEEP) had not been updated. This compromised the person’s safe evacuation should an emergency occur. Where identified actions were known to to staff and the leadership team, such as a broken washing machine, timely repairs had not taken place. This impacted upon people’s experience.

We received mixed feedback about staffing numbers. Feedback included, "I was buzzing for an hour this morning; I needed my feet covering up. There’s just about enough staff, I think” and “There are enough staff in the day and night."

Staff said there were not enough staff on duty to care for people safely. Comments included, “On certain units we need more staff,” “There is not enough staff. There are not enough nurses and [they are] too busy. Overnight, nurses are covering two units,” “Each unit needs to be run by a nurse. This is very important. This is a nursing home, and this is the main issue,” “The number of staff does not take into account the needs of residents” and “On some units there are [enough staff]. But on [1 unit] it can be dangerous due to [the needs of] the residents.” However, 2 staff members told us they used to be short staffed, but this was no longer the case.

Staff told us they mostly received appropriate training to fulfil their role. Feedback included, “We are trained well. The training isn’t an issue,” “We receive all sorts of different training, and it is enough to care for the residents” and “We have received all the training we need.” However, some staff did not feel confident in managing behaviour that challenged the service.

Staff told us they participated in supervision and had appraisals. However, some staff felt this wasn’t always sufficiently supportive and was a task based reminder of what needed to be done.

We observed people did not always have their needs met in a timely manner. For example, on the third day of the assessment, we noted 2 people leave their chairs who had been incontinent of urine due to their continence needs not having been met. We also observed people sitting for long periods of time in chairs with minimal activity. Whilst all care staff did make efforts to engage with people there was very little in the way of meaningful stimulation.

Systems and processes to support staff deployment were not always effective. Staff were often moving between units to provide support. Staff had not been listened to. Staffing had not been increased on 1 unit despite a high volume of incidents recorded and concerns raised by staff.

Systems and processes to support safe recruitment were not always effective. For example, 1 staff member did not have an up-to-date Disclosure Barring Service (DBS) check in place and their references were not robust. In addition, not all staff received an induction when they started working at the service. For example, 1 staff member’s induction was incomplete and 1 staff member had no record of induction having taken place.

Staff did not always receive training to enable them to support people safely. For example, records showed gaps in fire drill training for staff and basic life support.

People gave positive feedback about the cleanliness of the service. Feedback included, “Cleaners make it nice and clean. It’s what you want,” “They are always cleaning” and “It’s definitely clean."

Staff told us a washing machine in the laundry had been out of action for a few days and this had impacted upon the ability to ensure there were sufficient clean items of clothing, bedding and towels available to people. This increased the risk of infection.

The home was generally clean. We observed cleaning to be taking place throughout the assessment. Personal protective equipment (PPE) was available, and good attention was paid to staff and people hand washing before meals.

There was, however, a malodour in some people’s rooms and some people’s falls mats required cleaning. In addition, hand soap and paper towel dispensers were not always refilled. Clean clothing, bedding and towels were not always in sufficient supply.

The provider had systems and processes relating to Infection Prevention and Control (IPC) in place. However, gaps in quality assurance monitoring meant these were not consistently effective in ensuring all aspects relating to IPC were addressed.

People could not always have their medicines as prescribed because there was no stock available in the home. Twelve people had missed doses of their medicines in the previous 30-day period, 1 person could not have their anticoagulant, and another person could not have their medicine to treat stomach ulcers and reflux for 10 days because there was no stock. This placed people at risk of harm.

Medicines were not always administered in accordance with the prescribers’ or manufacturers’ directions. Medicines that should be given before food or on an empty stomach were given with medicines that should be given with or just after food, which meant that the medicines may not work properly. Pain relief patches that needed to be applied at the same time each week were applied late which meant the pain relief may not be fully effective for people.

When people were prescribed medicines and creams to be taken or applied ‘when required’ or with a choice of dose, the guidance to support the safe administration was not person centred. This meant staff did not always have enough information to tell them when someone may need the medicine, how much to give or which medicine to give if more than 1 medicine was prescribed to treat the same condition.

The leadership team completed audits. However, they had not identified the concerns regarding the safe management of medicines found during this assessment. For example, the October 2024 audit stated that all known allergies were identified on people’s medicines records, but 12 people did not have their allergy status recorded.

Systems and processes in place did not support the safe management of medicines.

The systems in place for recording the use of prescribed thickeners and the application of creams did not always show that people’s fluids had been thickened or the name of the cream that had been applied.

The process in place for administering medicines covertly, by hiding medicine in food or drink, or via a feeding tube in the stomach were not always safe because the medicines were not always supplied in a formulation that was suitable to crush or disguise.

The sites of insulin injections and pain relief patches were not always recorded which meant it was not possible to make sure the sites were not repeatedly used. This meant that people were at risk of their insulin not being absorbed evenly or skin irritation when patches were used.