Charles Court Care 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

We looked at all 8 of the quality statements within the key question of safe. This means we looked for evidence that people were protected from abuse and avoidable harm. At our last inspection we rated this key question requires improvement. At this assessment this key question has improved to good.

This service scored 72 (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 raise any concerns in relation to learning culture. People told us who they could speak with if they had any concerns. This included the registered manager, deputy manager, nurses and the operations director. Relatives knew who the manager was and confirmed they felt listened to.

Staff were aware of how to respond to incidents and accidents and could tell us how they record and report incidents. The registered manager was aware of the requirements of the duty of candour and the importance of sharing information with family and other stakeholders. This included apologising when things went wrong.

The provider had processes to learn from accidents and incidents to ensure people’s experiences were improved. Any learning was shared with staff to consider how incidents had happened and what could be done differently to improve practice. Where accidents or incidents had occurred, these had been recorded and analysed to determine the cause, identify any common themes, patterns and lessons learnt. Actions were taken to reduce the likelihood of recurrence. For example, where a person had experienced a fall, measures had been put in place to reduce the risk of this from happening again. This included making a referral to occupational therapy (OT) for a more suitable chair. However, we did identify 2 accidents and incidents were not documented on the monthly overview. We shared this with the management team who took action to ensure agency staff had access to record, report and share incident information effectively.

Relatives spoken with confirmed their loved ones were supported to access health and social care services when needed. For example, GP, district nurse, chiropodist and optician, and this was reflected in people's care notes. One relative said, “With regards to health appointments, GP or hospital, I am contacted to take [family member].” Another relative told us, “[Parents] have had visits from other health professionals at the home.”

The registered manager told us before people were admitted to the home, they carried out a pre admission assessment to ensure their needs could be met, this was evidenced in people’s care plans.

Some external professionals had positive experiences with the service. One external professional told us staff knew which services to contact and why. However, another external professional felt at times staff made referrals too quickly to seek help in some areas as opposed to monitoring first. Professionals made recommendations for improvements in these areas.

Processes were in place to ensure safe system, pathways and transitions were maintained. This included a pre admission assessment at the start of providing a service. This included communication needs, capacity, physical condition needs, medication, psychological and wellbeing needs, mobility needs, nutrition needs, personal hygiene, elimination needs, skin integrity needs, sleeping needs, activity needs and spiritual and end of life needs. Care plans were developed and contained important information. People’s changing needs were discussed within the staff team during regular meetings. Referrals to the multidisciplinary team had been made where appropriate. For example, requests via the nurse, for support from Speech and Language therapists (SALT). The provider was working through the local authority action plan.

People spoken with told us they felt safe. Relatives confirmed their family member was safe. One relative said, “Staff do support [person’s name] care needs during the day to keep them safe.” Another relative told us, “I do believe [family member] does feel safe and I am happy with them in the home. I’ve no concerns although there are times when staff are very busy and may not be able to give [family member] as much care support as they need.”

Staff told us they knew how to report potential abuse. One staff member said, “I would speak with senior, or the nurse on duty if I had any concerns about people.” Another staff member told us, “If I was concerned about any residents I would go to the nurse, if in an emergency I would call the bell." A further staff said, “I would report to the nurse, then the manager (depending on who I see first). If the concern was about the manager I would go higher. I would report to the operations director. If felt not listened to or addressed I would report to the local authority or yourselves (CQC). We (staff) have access to policies and procedures.”

We observed staff speaking with people in a respectful way and involving them as much as possible in decision making. We saw staff responded to people promptly when they needed support. However, we observed call bells were busier upstairs than downstairs. Staff were seen to ask consent before supporting people. People appeared comfortable and relaxed with staff supporting them.

There was an up-to-date safeguarding policy in place. Safeguarding policy and processes ensured safeguarding referrals to the local authority as well as notifying the Care Quality Commission (CQC) were made when required. Records showed 86.5% of staff had completed safeguarding adults eLearning and safeguarding combined: adults and children and young people training. Where people were being deprived of their liberty, applications had been sent to the local authority for authorisation. There was a tracker in place to monitor and ensure authorisations were current, valid and to take action when they were due to expire. To ensure full oversight of when they had followed up applications which had not been authorised we suggested the provider consider adding this additional information to their tracker.

People told us they felt safe, and relatives felt risks to their loved ones were fairly well managed. Where people required equipment to support them to transfer, they told us staff were capable and skilled in assisting them. One relative explained how their family member used a hoist to be transferred from their bed to the wheelchair, then used a hoist from the wheelchair into the lounge armchairs, for afternoon activities. The relative said, “Two staff members seem to safely use the equipment.” Another relative told us how their family member had a sensor mat by the door to alert staff members when they were up and walking around, to prevent them from walking into other people’s rooms. A further relative described how their family member’s health had deteriorated due to their dementia and depression and how staff had learned to distract them, as a strategy to try and reduce their anxiety and said, “It does seem to be working.” However, some people and relatives told us call bells were not always responded to promptly when assistance was needed. We shared this with the provider who showed us they regularly reviewed their call bell logs and timescales of responding to people. Audit carried out on the 7 October 2024 stated some people reported bells were not always answered promptly and as a result of this further action was taken. Subsequent audits did not identify any concerns, with call bells answered promptly.

Staff understood risks to people and how to support them safely. Staff told us they had enough detailed information in care plans which were accurate and up to date. One staff member said, “The nurses are responsible for care plans and risk assessments. We (care staff) can tell the nurses of any changes, share information or any concerns with them and they will follow up and update care plans and risk assessments accordingly.”

Staff were observed using equipment safely. We observed staff supporting people safely around the home and during activities. People were supported by staff in a way which was supportive and respectful. Staff were patient and supported people at their own pace.

Risks associated to people's individual care needs had been assessed and plans were in place to manage these. These included risks associated with health, mobility, nutrition and hydration. However, risk assessments did not always demonstrate who had been involved. Regular checks had been carried out on the premises and equipment to ensure people’s safety. This also included checks by external contractors. For example, fire safety checks.

People and relatives did not raise any concerns in relation to the safety of the environment or equipment. One relative said, “I have observed staff safely hoist [family member] from a to b using the equipment.”

Staff spoken with did not express any concerns about the environment. They told us any issues with the environment or equipment were recorded and reported to the maintenance team.

We observed communal areas to be clean and tidy and fit for purpose. There was signage to help people with dementia orientate around the home.

Processes were in place to monitor the safety and upkeep of the premises . The provider carried out the necessary environmental checks in line with current legislation. Systems and processes were in place to monitor these regularly.

People were complimentary about staff. Comments included, "Its lovely (here), staff are attentive," "I love the staff they are wonderful," and "90% of the time staff are attentive, always exceptionally good, and there are usually people are around." Relative’s comments included, “Staff do support [family member’s] care needs during the day to keep them safe,” and “[Person’s name] is very happy in the home and feels quite safe,” However, although relatives felt their loved ones were safe the majority spoken with shared the biggest concern was how busy staff were, staffing levels and turnover. Relatives told us they were concerned the use of agency staff may have a potential impact on their family members needs being met, due to staffs lack of understanding and/or knowledge of the people they were supporting.

Staff spoken with told us they enjoyed their role and felt well supported. They told us they received appropriate training and supervision. Staff spoke positively about the staff team, improved team working and morale, but felt staffing levels could be improved. There was a consistent message from staff which was they were busy. The service relied on agency staff to cover shortfalls such as vacancies and staff absences, these were consistent agency staff as much as possible.

We observed staffing arrangements met people’s needs when required during our onsite assessment. We did not see people being rushed or their needs not being met. The home felt calm and relaxed and positive interactions were seen.

People were cared for by staff who had been recruited safely. All relevant pre-employment checks had been carried out. This included reference checks, proof of identity as well as Disclosure and Barring Service (DBS) checks. A DBS check is a way for employers to check an employee criminal record, to help decide whether they are suitable person to work for them. This protected people from receiving support from unsuitable staff. Any gaps in employment had been explored with any reasons recorded. New staff received an induction when they started and ongoing training to support their job role. Staff were involved in regular handover, flash meetings, unit and staff meetings to share information.

People and their relatives all felt the home was clean and well maintained. One person said, “The cleaner comes in each day to clean the tables down and help tidy my room.” A relative told us, “The home is a purpose-built building, very light and modern. Its clean and the environment is nice and welcoming.” The only negative comment made in relation to cleanliness was on occasions some felt their family members bedroom had an odour. We shared this with the management team who assured us they would address this. For example, increase deep cleaning.

Staff were provided with personal protective equipment (PPE) and there were no issues with the supply of cleaning products. However, one housekeeping staff member told us they did not always have enough time to complete their tasks . The registered manager told us the deputy manager was the infection control champion for the home.

The premises appeared visibly clean and well maintained. Staff were observed to be wearing appropriate personal protective equipment (PPE) for the task they were carrying out. We did identify one black bin in a bathroom where the peddle had gone and one person's chair appeared dirty with food debris and stains. We shared this with the management team who assured us they would address this without delay. We did not identify any other concerns in relation to infection control. However, partners told us they had identified issues with Infection Prevention and Control (IPC) and had made recommendations for improvements in this area.

Staff had received training in Infection, Prevention and Control and had regular refresher training. The staff training matrix confirmed this. Regular IPC audits of the home were carried out and cleaning schedules were in place and undertaken by housekeeping staff. In addition, there was a regular cycle of an external company who came into the home to carry out deep cleaning.

People and relatives did not raise any concerns with us about the safe management and administration of medicines at the home. However, one person did say, “I could ask a nurse and get a paracetamol, but it may take a while to get them though." A relative told us, “I do believe the staff administer [relatives names] medication whenever they need it. Staff do consult with me if there are any changes in their medications.”

We observed people receiving their morning medicines in a timely manner and in a safe way on the ground floor. However, on the first floor we observed the morning medicines round took longer to complete. We then observed the lunchtime medicines being administered on the first floor. This meant there was potentially only an hour gap between medicines, and we could not be assured staff had sufficient time to administer medicines and people were always receiving their medicines safely and as prescribed. We raised this with the management team who told us they had reviewed this and were assured people were receiving their medicines as prescribed. The registered manager told us, following our findings there would be a period of medicines observations. In addition, the registered manager told us following our findings the deputy manager would be assigned to work with the nurses to look at time management, and what support is required, and they will increase the frequency to complete observation of practice to identify any risks, and how to mitigate.

We found some shortfalls in medicines processes. This included 2 people’s MAR charts did not contain a photograph of the person. Some creams were seen dated as opened however, for one person there was no guidance on where to apply or how often. Catheter care plans required more detail to include catheter care bag changes and care of the drainage port. The registered manager provided us with assurance and confirmed they would complete a full review of all catheter care plans to ensure information is referenced. Some people’s epilepsy care plans contained more instruction on subsequent actions than others. Following our visit the registered manager confirmed these have been reviewed and updated to ensure they are detailed, and person centred. The registered manager and deputy manager were both registered nurses and were therefore qualified to carry out the medication administration and management competency checks of nursing staff.