Chandos Lodge 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 inadequate.

This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment, safeguarding, staffing and recruitment.

This service scored 31 (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 always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The service maintained a folder labelled ‘learning culture’ which contained records of incidents and notes of discussions with staff. However, we were not assured there was effective oversight to ensure learning was consistently identified, shared and embedded in practice to improve the quality and safety of the service. For example, staff did not always recognise safeguarding concerns. Incidents of verbal and physical abuse between people were not consistently identified or responded to, with no formal debrief following such incidents to support reflection and learning. This meant the service did not put effective practices in place to prevent reoccurrence and keep people safe and prevent them from harm.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services

Whilst the provider had systems in place to support safe and coordinated care, including for people admitted from hospital with high care needs, these systems were not effective. Care records such as moving and handling assessments were incomplete and other records relating to supervision of people were contradictory as the level of observations and checks they required putting people at increased risk of falls. Alongside this there were delays in recognising and reporting incidents of verbal and physical abuse, which put people at risk of harm from others. Although the service engaged with other health professionals, these gaps meant the provider could not be assured that systems and pathways consistently supported the timely, safe and coordinated delivery of care.

A relative told us how they were not sure of the frequency of pad changes and reported that when they visit, they find their family member in wet and soiled pads which they themselves attend too. This meant that systems to plan, deliver and monitor personal care were not consistently effective, as staff were not always providing care in line with assessed needs.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

Safeguarding systems and processes were not effective in protecting people from abuse or improper treatment. The provider’s safeguarding policy was out of date and not aligned with the local authority multi agency safeguarding procedures. The policy indicated staff should seek a person’s consent before making a safeguarding referral and records showed this approach was being followed in practice. This did not reflect the providers duty of care to raise safeguarding concerns where people may be at risk.

Records showed safeguarding referrals had not been made for incidents that put people at risk of abuse, including incidents of abuse between people using the service. There was a delay in making a safeguarding referral for concerns relating to the development of a pressure sore. These delays placed people at increased risk of abuse.

We also identified environmental risks which had the potential to impact people’s safety and privacy. Two-bedroom doors had locks fitted on the outside rather than inside, which meant people could be locked in from outside the room. In addition, one bedroom had an interconnecting door to another bedroom, occupied by a person of the opposite sex, which presented a risk to people’s safety and privacy. The provider had not assessed or mitigated the risks associated with these arrangements. The provider took action at the inspection to remedy the door locks.

As a result, safeguarding concerns were not consistently recognised or referred to the local authority, and risks within the environment had not been adequately addressed. This meant potential abuse or harm was not always subject to appropriate external oversight. These failings meant the provider could not be assured that people were safeguarded from the risk of abuse or improper treatment.

Although staff had completed safeguarding training, discussions with them showed they were not confident about escalating concerns outside of the service and could not clearly describe when concerns should be referred to external authorities.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The provider did not consistently identify or manage risks to people. People’s records did not reliably evidence that people received care in line with their identified needs, including support with mobility, mouth care to minimise the risk of choking, timely repositioning and incontinence pad changes, and guidance for managing behaviours of distress was not comprehensive. A person’s records evidenced that they did not receive personal care for 12 hours, increasing the risk of skin damage and discomfort. Another person with epilepsy had a care plan that indicated oxygen should be used as part of the recovery process. However, there was no guidance on how the person’s epilepsy symptoms might present, or how and when oxygen should be administered. This put people at risk of harm from known health conditions and skin pressure damage.

For people who presented with distressed behaviours, care plans included guidance on de-escalation, but did not provide instructions for staff on what to do if these techniques were not effective, leaving risks unmanaged. Records viewed showed incidents where de-escalation strategies failed, placing both people and staff at risk of harm.

When people were at risk of absconding, we found no guidance for staff regarding what they needed to do, if a person left the service unnoticed or without supervision. This was compounded by contradictory records, with some records indicated that the person required one to one observation whilst others recorded the person required 2 hourly checks. The lack of effective risk management created the potential for inconsistencies in supervision, which increased the risk of absconding and putting themselves at risk of harm.

The failures in identifying and managing risks meant that people were exposed to avoidable harm and the provider could not be assured that care was delivered safely and effectively.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The provider did not ensure the environment was consistently safe for people, staff and visitors. A free-standing electric heater was in use with a risk assessment indicating it was secure. We observed it was not fixed to the wall, had wires trailing and placed people at risk of burns and injury.

Hot water temperatures were consistently recorded as being too hot. Staff responsible for carrying out these checks were not aware of safe water temperature limits. The recording template also provided incorrect guidance, indicating the hot water temperature should be at and up to 50 degrees, which is not in line with Health and Safety Executive (HSE) guidelines. In addition, the thermometer used to check water temperatures had not been calibrated, with no system in place to ensure its accuracy. The shortcomings in monitoring and awareness meant people were not protected from the risk of scalding.

The rear external door was not secure, and people were able to access an area where they could climb over the fence, creating a risk of absconding and injury to people. Other storerooms including one containing electrics were not locked which further placed people at risk of harm.

A number of relatives raised concerns that the front door was not sufficiently secure, as it could be open by pressing a button. They told us it was not consistently monitored when visitors left the service, which meant there was a risk people could leave the premises unsupervised and placed people at risk of harm.

Named fire wardens were recorded as the manager and a staff nurse on night. However, during the inspection, the manager was not on duty, and no alternative fire warden had been delegated, leaving gaps in fire safety responsibilities. Fire drills were not conducted in line with the providers guidance, with only 2 drills completed instead of the required 3 and none had taken place at night. The fire drill records did not show that all staff including agency staff participated in practice evacuations. This meant the provider could not be assured staff knew how to use required evacuation equipment, and people were placed at risk of harm. In response to our draft report the provider confirmed a number of staff were trained as fire wardens and they have updated their documentation to reflect that.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

The service had a dependency tool in place to support them in determining the staffing levels per shift; however, we were not assured it had been applied appropriately. Records showed people receiving one to one care and support had been assessed as a medium dependency, which did not accurately reflect their needs. This meant the provider could not be assured that staffing levels identified on the rota were based on an accurate assessment of people’s care needs.

The staffing levels deemed required by the service were not consistently provided. Rotas showed staff consistently finished shifts at 18.00 and 19:00 and this left 1 carer and 1 registered nurse to support 21 people for the remainder of the late shift. In addition, during training on the 12 January 2026 (9.00-16.00) and on 6 February 2026, from 18.00 there was no registered nurse on shift. This meant there were not always sufficient qualified staff to safely support people’s individual needs.

Most relatives told us the staffing levels seemed sufficient, with one relative telling us that there appeared to be fewer staff at weekends, A relative, however reported that staff always appeared busy during their visit, and they assisted their family member with personal care. This was to promote timely access to the required care.

The provider had not ensured staff received appropriate training to carry out their roles effectively. Training records showed staff completed multiple modules in a single day, with no evidence the training was understood or embedded in practice. At the time of the inspection, records for 2 agency staff working in the service showed their training was out of date. They had not received training to manage distressed behaviours, however, they were supporting people on a 1:1 basis with distressed behaviours. The staff member in day-to-day charge of the service did not have training relevant to their role. Maintenance staff had not received training in water safety requirements, which meant they did not recognise that the water temperatures they were recording were too hot. The training matrix did not include all staff who were employed at the time, and we were informed that a staff member who was on maternity leave had come in to cover a shift without relevant up to date training recorded. Therefore, people were supported by staff who did not have the required knowledge skills and competence to fulfil their roles safely.

Whilst staff told us they felt supported, supervision was not effective or comprehensive. Supervisions for all staff took place in March and December each year and not every 3 months as was outlined in the providers supervision policy. Records were brief, had no standing agenda items and did not review individual training needs. They did not assess whether completed training had been embedded in practice. As a result, the provider had not assured themselves that supervision was supporting staff to carry out their roles safely and effectively. In response to our draft report the provider confirmed the supervision template record had changed in January 2026 and it covered wellbeing, responsibilities and competence, infection prevention and control, safety privacy and dignity, training and development, support and actions needed.

Recruitment practices were not safe. One staff member did not have an up-to-date Disclosure and Barring service (DBS) check, and no references had been obtained. For other staff gaps in employment were not explored and another staff member had no risk assessment for a medical condition, which could impact supporting people with moving and handling.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading.

Whilst staff were trained in infection control, systems were not in place to be assured infection control risks were mitigated. Slings used for moving and handling manoeuvres were shared between people using the service, which increased the risk of cross infection.

There were no audits of infection prevention and control practice, other than audits of infections such as chest and urinary tract infections. This placed people at risk of avoidable infection.

There were no records available to demonstrate that wheelchairs and shower chairs were routinely cleaned. We observed a shower chair with a rusty frame in an ensuite shower room and a person’s bedroom had a strong malodour and a stained fabric chair with no cushion.

In another bedroom a large leather chair was observed to be worn and torn, meaning it could not be effectively cleaned, increasing the risk of cross infection. The ground floor toilet had a strong damp odour indicating that the environment was not being maintained to an acceptable hygienic standard. This meant people were at risk of being exposed to the risk of infections and associated harm.Following the assessment, the provider told us they have made changes to their systems and processes to address the concerns identified. We have not assessed these changes as part of this inspection, and these improvements will require time to become fully embedded in practice.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Medicines were not consistently managed in line with best practice. Although the provider had a system to monitor and audit people’s medicines on a regular basis, we found that they were not always effective and improvements had not been made. For example, on the day of inspection we found that 1 person had previously had their medicine administered to them twice a day instead of once a day. This had not been picked up by the provider as part of their monitoring. Therefore, we were not assured that medicine errors were investigated properly with appropriate action taken. Although there were processes in place to ensure staff learned from these incidents to prevent them occurring again, we did not see any medicine related incident reports from the past 12 months. Furthermore, the latest medicines policy was out of date and had not been updated to reflect the provider’s current medicines arrangements.

A number of people were prescribed flammable creams such as cetraben. There were no risk assessments in place identifying the known risks associated with flammable creams, leaving staff without guidance to manage potential fire hazards associated with their use.

People mostly received their medicines as prescribed.We looked at seven people’s medicine records and found one discrepancy in the recording of medicines administered. Overall, the provider was assured that people received their medicines safely, consistently and as prescribed.

There were separate charts for people who had medicines such as patches, ointments and creams prescribed to them (such as pain relief patches). Furthermore, medicines when required, were disposed of regularly and appropriate records were made.

During the inspection, we saw several instances of where people were prescribed PRN (as required) medicines and there were associated PRN protocols in place. This meant staff were able to administer these types of medicines effectively to people within appropriate clinical guidance.

There were 4 people who received their medicines in a covert manner and appropriate authorisations had been sought to enable them to have their medicines safely. We observed appropriate medicines administration to people, including the use of hand hygiene prior to each administration.

There were systems for ordering, administering and some monitoring of medicines. Staff were trained and deemed competent before they administered medicines. Medicines were safely secured and records were appropriately kept. We found that room and fridge temperatures were appropriately monitored.