Charnwood 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 identified two breaches of the legal regulations. People were not supported to be safe from abuse. This is because when concerns were raised by people, these concerns had not been acted on by staff. Staff reported that people’s personal care needs were sometimes neglected by other staff, but these concerns had not been raised as a safeguarding concern. Safety risks to people were not managed well. Staff did not have clear written guidance or training on how to support people safely. This could impact the effective working with external health and social care professionals. Staff were not effectively deployed around the care home. People with mental health needs were not supported in a safe environment. We observed areas both inside the care home and in the garden; that contained items that would be risky to people living with confusion. The home was clean and staff had access to personal protective equipment to support the spread of infection. Medicines were managed safely. During the assessment, we raised concerns with the management team. There was a lack of effective action taken to resolve the two breaches of the legal regulation.

This service scored 41 (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 always experience a positive culture, where staff and the management team learned from mistakes. This is because we reported concerns about poor quality care, and we saw people continued to experience the same poor quality support on our second site visit.

Staff told us that they felt incidents were not formally discussed within the staff team. This meant incidents were not effectively learnt from.

During the assessment, we identified multiple concerns. We reported these concerns to the senior management team. There were ineffective processes to ensure lessons were learnt and improvements were then made. For example, we expressed concerns that it was a warm summer’s day and the building was too warm (measuring at 30 degrees celsius). There were no processes to ensure people were supported to be comfortable in this heat. When we returned, we saw the building temperature had increased to 32 degrees celsius. Ineffective measures had been put in place to cool the building. Records suggested people were still not drinking enough. Staff had received no communication on how to support people to be comfortable in the hot building.

Staff did not have clear documentation on how to support people’s health needs. This could impact people’s experience when transferred to other services (like going to hospital). For example, we observed a person experiencing hallucinations. Staff explained that this was a regular symptom for them. However, this information was not recorded in documentation. So if the person went to hospital and hospital staff took this documentation; then hospital staff may not realise that hallucinations were a usual presentation for this person. Relatives reported that staff were not always aware when medical professionals had given advice. They said they needed to explain updates to staff.

Staff explained that they were in regular communication with external health professionals (like the local GP surgery). Staff were able to explain when they call for emergency paramedic advice, and how the care home’s nursing staff would support the person to stay safe while they waited for the paramedics to arrive. While staff were able to explain this, records were not always clear on how people’s health needs should be supported. Therefore, we were not assured that there would be effective communication with other professionals.

We received no feedback from visiting health professionals.

The care given to people was not well recorded by staff. If visiting health professionals reviewed these records, the poor record keeping could impact the safety of care they provided. For example, a person was recorded as not going to the toilet for long periods. Staff explained that they person had gone to the toilet regularly but staff had not written it down. Not writing down when the person used the toilet, could result in a visiting health professional reading the records and becoming concerned about the person’s risk of constipation.

One person told us that staff were ‘rough’ when caring for them and this had caused bruising. Staff had recorded this bruising two months ago, however had not taken action to refer to the safeguarding team. Another person explained that a staff member had hit them twice. We reported this to the management team to investigate. Due to the reports of these two people, we were not assured that people were safe from abuse. Or that staff would act effectively if abuse was reported to them.

Staff told us that they felt confident recognising the signs of abuse. However, multiple staff reported that people were sometimes neglected by staff at the service. These concerns had not been flagged by staff to the local authority safeguarding team or to their management team. We were therefore not assured that staff would effectively act on abuse concerns.

Whilst we did not observe any abuse while at the service we could not be assured people were protected from the risk of abuse based on other evidence categories.

The service had a safeguarding policy in place. Staff had also received training in safeguarding. However, these processes had not resulted in people being safe from abuse. We reported our concerns to the senior management team, when we returned 2 days later, we found limited action had been taken to investigate the allegations and keep people safe from harm. We were therefore not assured of effective management processes to keep people safe from abuse. Some people at the service were subject to a Deprivation of Liberty Safeguard (DoLs), this is where the person cannot make decisions about their care and treatment. So restrictive care arrangements are legally authorised in the person’s best interest. We found staff had poor knowledge of DoLs and how these impacted people. Some DoLs authorisations were made, with conditions in place. However, these conditions were not met by the staff team. For example, one person’s deprivation of liberty was authorised on the condition that they were consulted on what activities they would like to take part in. Then regular activities should be offered. We saw the person had not been consulted on what activities they would like to do, nor were they offered meaningful activities.

People were unable to answer questions about risk. However, records kept by staff and our observations of the environment. Showed us that people would not have a positive experience.

Staff told us that they felt the staff team were not sufficiently skilled to support the people living at the service. When we reviewed the training records, this confirmed the staff feedback.

During the assessment, we saw staff were quick to intervene when people were seen to be at immediate risk. For example, we saw a person start to use a walking frame that was designed for someone else. Staff quickly supported the person to change to their own walking equipment. However, records showed that people had been in other people’s bedrooms without staff intervening. So we were not assured that staff always responded quickly to risk.

Risks associated with people’s physical and mental health needs were not safely supported. Care plans did not include clear guidance on how to support people safely, and reviews of these documents were ineffective. For example, one person’s care plan guided staff to change a person’s medical device. However, it had different timescales for how often this should be done. Records showed that medical device care was provided sporadically. This can risk serious ill health for a person. The management team advised improvements had been made to record keeping, but we saw the same inconsistencies in place after this review occurred. We saw staff did not always document people’s wellbeing or presentation. This could impact the ability of the service to manage risk. A staff member told us, “Sometimes people will say someone needs one to one. However sometimes it’s difficult to make a decision if some carers do not document or do not indicate the extent of the behaviours that the residents are portraying.”

People were unable to answer questions asked about the safety of the environment. However, we observed people did not always live in a safely maintained environment.

Staff were able to explain how they ensured people would be safe in the event of a fire. They were also able to explain the maintenance procedures in place, to ensure that the water in the care home was protected from legionella bacteria.

People with mental health needs were not supported in a safe environment. We observed areas both inside the care home and in the garden; that contained items that would be risky to people living with confusion. For example, some people’s bedrooms had unsecured objects that could fall on people, loose razors that could cut people, and denture cleaning tablets that could be swallowed. External garden areas were overgrown with nettles and not sufficiently blocked off so people could access these areas and hurt themselves. Care records showed people often walked around the care home with confusion. Staff told us they felt unable to manage this risk, and there was a lack of guidance for how to keep people safe when walking in this unsafe environment. We reported our concerns about the environment to the management team. When we returned two days later, we saw the same concerns remained. There had been ineffective action to improve the safety of the environment.

There were ineffective processes in place to ensure the care home was well maintained. We saw a person’s bedroom had a sharp broken towel rail which could injure them. We reported our concern about the damaged towel rail to the management team. When we returned two days later, this had been replaced and the area was now safe. Staff had also been told by the management team to report concerns. However, effective action had not been taken to maintain other areas of the care home. This is because on our second assessment day, we observed another person’s bedroom carpet was lifting and causing a trip hazard.

Three people told us that staff were sometimes slow to respond when they pressed their call bells. There had been no audit of how long it took staff to respond to call bells. So we were unable to assess how long waiting times had been. People told us that staff were not always effective in the care provided. They explained that staff were not always skilled to know how to support them. One relative explained that they had concerns about a person’s medical device and had to speak to multiple staff until one understood how to resolve the issue.

Staff felt not all staff were well trained. They explained that rotas were not well organised, so there was not always skilled staff working on every shift. One staff member said, “There isn’t a strong skill base on all shifts. So sometimes we find no one has specific training to understand something.” Staff explained that the induction had not prepared them well for their role. We saw the induction paperwork did not clearly cover all aspects we would expect staff to be skilled in before starting work. Staff explained that the induction was rushed, as experienced staff felt guiding new staff would “hold them back” and prevent them from completing all the required care tasks. Staff felt that the training was not always effective. They explained that a large amount was online and they would like more face to face training. One staff member explained that they had seen other staff unsafely move people. They had corrected this practice but were concerned that these staff had received training but were not working safely despite being trained. Staff explained that there were usually enough staff, but at times staffing was not well distributed through the building. One staff member explained that they could see a person with dementia going into another person’s room. However, they felt unable to leave the communal lounge to redirect the person. This is because it would leave people in the lounge at risk and unattended too.

We saw there were enough staff to support people safely. However, these staff were not always effectively organised and deployed. This meant some areas of the care home were left with minimal staff in place. Whereas other areas of the home had multiple staff available to people.

We reviewed training documents at the service. These documents showed that staff were not always suitably trained to provide safe care. Some people living at Charnwood, had indwelling medical devices. These are medical devices that inserted inside a person’s body to help their health (like catheters, stomas, and feeding tubes). Staff had not received training in how to manage these devices. When we reviewed people’s daily records, we saw people may not be receiving safe care for these devices. So we were concerned that staff were not skilled enough to keep these people safe. We expressed concerns to the management team and were assured that skilled staff would be arranged for these medical devices. However, when we returned on the second assessment day; the staff had not received any further training. There was only one person on shift who had training, and none-trained staff were providing care for these devices. We therefore remained concerned that processes were not in place to arrange skilled staff. Where staff had received training, we were not assured that this resulted in safe care. For example, staff had received training in food hygiene, but we saw food was presented to people at unsuitable temperatures. The staff team were not all aware what safe temperature the food should be served at – despite having received the training.

People felt the care home was kept clean. One relative said, “The domestic staff are very good. It is clean, they keep it wonderful.”

Staff were aware of how to access personal protective equipment and when to use it. Training records showed staff had been trained in how to prevent the spread of infection.

Walls and surfaces around the home were damaged and scratched. This would impact staff’s ability to clean these surfaces effectively. Other than this, we saw the home was clean.

Staff had suitable personal protective equipment in place. This meant they could use this equipment (like gloves) to prevent the spread of infection. Staff had clear processes on how to clean the care home, including which areas were cleaned on what day.

People had a good experience with their medicine. Their medicine was given as prescribed by trained staff.

Staff were able to explain how they managed people’s medicines safely. One staff member said “I make sure I have the correct person and room number. I then read the medicine charts to make sure I have the right medicine, right dose, right time and right route of the medication (oral or topical)”

Staff kept clear records of when they had given prescribed medicines. Staff did regular checks of the amount of medicine in stock. This ensured that suitable stock levels were always in place, and more medicine could be ordered from the pharmacist as needed. Some people required ‘as needed’ medicine and staff had clear written guidance on how this should be administered. Staff had received training on how to administer medicines safely.