Chandos Lodge Nursing Home

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate.

This meant there were widespread and significant shortfalls in people’s care, support and outcomes.

The service was in breach of legal regulation in relation to person centred care and consent.

This service scored 29 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not make sure people’s care and treatment was effective because they did not check and discuss people’s health, care, wellbeing and communication needs with them.

The provider did not always carry out robust assessments to ensure the service could meet people’s needs safely. The provider supported people they were not registered to do so, for example people with dementia. In addition, assessments did not consistently consider whether people were compatible with other people already living at the service which resulted in people being harmed due to incompatibility. As a result, people were at risk of receiving care that did not meet their individual needs or reflect their preferences.

The assessment process was not always thorough. In some cases, assessments consisted of a telephone discussion with hospital ward staff rather than a face-to-face assessment of the person. This limited the provider’s ability to fully understand people’s needs, risks and the impact their admission may have on others living at the service.

As a result, the provider could not be assured that people’s needs had been fully assessed before admission or that the service was able to safely meet those needs. This placed people and others living at the service at risk of harm.

The provider did not plan and deliver people’s care and treatment with them, including what was important and mattered to them.

The service was not consistently working in line with recognised best practice across key areas of care. These included safeguarding, consent, risk management, medicine management and support for people with behaviours of distress. Alongside this, care was not person centred and did not consistently meet people’s individual needs.

People who required support with repositioning to reduce the risk of skin pressure damage, records did not consistently evidence this support was being offered within the prescribed timeframes. This meant people were at risk of not receiving care and support in line with best practice guidance.

People’s risks around food and nutrition were identified. People were offered a range of meals. However, there was no system to ensure people who were at risk of dehydration received the required amounts of fluid. For example, a person had a target of 1,500 millilitres of fluid daily. Over a period of 3 days this target was not met, and the shortfall was not identified or escalated, placing the person at risk oof dehydration.

Relatives generally felt that their family member was kept well-nourished and the meals provided were appetising and looked good. Some relatives reported that their family members had lost weight, with 1 relative noting this was due to a decline in appetite. However, relatives were unsure whether any action had been taken, such as referrals to a dietician or the use of dietary supplements to manage their family members nutrition.

The provider did not work well across teams and services to support people.

The service had processes in place including daily handovers and a ‘resident of the day’ system, to support staff to share information. However, these processes were not effective in practice, as they did not consistently identify shortfalls in care plans or risk assessments that we found and no updates were made where these were required. As a result, we saw staff did not have the required information to support people’s health needs in relation to the management of epilepsy and their behaviours of distress which we saw impacted staff and other people.

Team meetings were held but did not routinely include discussion about people to support a coordinated approach to their care. Minutes of team meetings referred to discussions about staff practice and work processes. These lacked detail and did not promote effective communication across the team, providing little guidance or information for staff who were not on duty at the time. Alongside this, staffing levels reduced on the late shift, limiting opportunities for comprehensive handovers and effective communication across the team. This meant that staff were not consistently working together to share information, coordinate care and ensure people’s needs were met.

The provider did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control. Staff did not always support people to live healthier lives, or where possible, reduce their future needs for care and support.

The service provided people with access to a visiting GP and other healthcare professionals such as the mental health team, community chiropodist and dentist. However, some people were admitted whose needs the service and the environment could not meet, such as people at risk of absconding.

Staff were not routinely following physiotherapists advice or supporting a person to do exercises to prevent a deterioration in their medical condition. This meant the service did not consistently support people to live healthier lives.

The provider did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

The service reviewed and audited care plans regularly. However, these were not effective in identifying shortfalls in practice. For example, records for personal care, oral care, repositioning and physiotherapy recommended exercises showed that people were not consistently receiving the support they needed. We observed that people did not always have positive outcomes. For example, due to lack of personal care offered people suffered avoidable discomfort. The provider’s own systems failed to identify gaps in care meaning people were not consistently receiving support that promoted positive outcomes. This meant people were put at increased risks from known health conditions and did not consistently receive the personal and oral care they required.

The provider did not tell people about their rights around consent or respect these when delivering care and treatment.

Staff training in the Mental Capacity Act 2005 (MCA) had not been embedded in practice and as a result staff were making decisions without reference to legal requirements. The provider did not ensure compliance with the MCA. Mental Capacity Assessments and Best Interest Decisions (BID) were incomplete, with section 3 of the BID left blank meaning decisions could not be justified as being in people’s best interests.

There were no assessments or best interest decisions for people being given vaccinations. The service sought consent from family members without assessing people’s capacity first or making a best interest decision involving people’s relatives or representatives. This practice does not comply with the requirements of the Mental Capacity Act 2005.

Not all people had a mental capacity assessment or BID records for the use of CCTV in communal areas of the service.

A person’s call bell had been removed as the service deemed it to be “overused”, without a mental capacity assessment to support the intervention or consideration of less restrictive options. The person’s care plan incorrectly identified who held power of attorney, demonstrating that decisions were made without compliance with the Mental Capacity Act 2005.

These meant people were at risk of unlawful restriction and breaches of their human rights.