Chilmington House

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 Good. At this assessment the rating has remained Good. This meant people were safe and protected from avoidable harm.

This service scored 63 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The provider had systems in place to ensure any incidents, accidents or complaints were recorded, investigated and acted upon. However, there had been no recent incidents or complaints. Relatives were aware of how to make complaints.

Staff knew how to raise concerns, 1 staff member told us, “[I would report] incidents, medication errors and safeguarding concerns. I will report them by informing a senior staff in duty and complete an incident report form accordingly in relation to the workplace policy and procedures.”

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

People were safely supported to transition from hospital or from another care service. Upon admission to the service, a holistic approach to care was followed to support people to manage their care with other providers. This included registering people with the local GP surgery, arranging medicines, liaising with the district nurse team and other health professionals.

One person had moved into Chilmington House from another provider and the team had arranged a new wheelchair for them and facilitated a move to a more inclusive life. This meant they worked well with other professionals to give the person the best quality of life possible.

One relative told us, “[Chilmington House] try and meet all [their] needs, if [person] shows interest in it, they are on it, [person] has come on leaps and bounds since being there, [Person] had poor care prior to Chilmington House.”

One professional said, “I have worked with this service for [many] years, and they are easy to contact and always respond in a timely manner. They reach out for support when needed.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Staff had applied to the local authority for Deprivation of Liberty Safeguards (DoLS) authorisations. The manager had a record of all DoLS applications that had been made, including details of any conditions to the authorisations.

People told us they felt safe living at the service. For example, 1 person told us, “Yes, I feel safe here.” All relatives we spoke with told us they felt confident their loved one was safe. One person’s relative said, “Yes, absolutely safe. The staff are very attentive and know [them] well.”

Staff had been trained in safeguarding and understood their responsibilities in reporting safeguarding concerns. One staff member said, “We do the training every year. It’s to protect the residents from any abuse or anything that can harm them. We protect the residents and look after them. We make them feel safe because this is their home.”

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Systems were in place to ensure risks people might face were routinely assessed, monitored and reviewed. People’s care records contained detailed guidance for staff to follow. This ensured risks people might face were mitigated, so people remained safe when taking part in activities of daily life. Managers and staff were fully aware of the potential risks people might face and the steps they needed to take, to reduce or safely manage them. Risk assessments and care plans were reviewed at regular intervals and updated according to reflect any changes in people’s needs.

Communication needs were clearly documented within individual hospital passports to support other care providers in understanding how best to engage with and support each person. While these passports contained relevant and helpful information, they were not consistently comprehensive. However, the information already available in the passport means that any person needing treatment elsewhere should be able to be communicated with in an appropriate and reassuring manner.

Staff told us, “[We] involve people to help them[selves] by letting them make their own choices.” And, “[We] respect their choices and decisions. We focus on what they can do and help them do this with support.”

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.

A number of environmental risks were identified which had the potential to impact people’s safety. Not all windows had appropriate restrictors in place, which increased the risk of harm. A heater in the hallway was found to be insecurely attached to the wall, presenting a potential hazard, particularly for people who use wheelchairs. In addition, a fan within a bedroom had not undergone Portable Appliance Testing (PAT) since 2020, posing a potential electrical risk.

Maintenance issues were also observed in the kitchen, where cupboard doors were missing, increasing the risk of injury to both staff and people using the space. Cleaning fluids were stored in an unlocked cupboard within the utility room, meaning potentially hazardous substances were accessible and could cause harm.

Security concerns were identified in relation to the front door, which was found to be unlocked on arrival. Management acted promptly to address this when it was raised; however, during the visit, the door was again found to be unlocked and open, as the locking mechanism had been disabled for a second time. This placed people at potential risk, as unauthorised individuals could gain access to the home.

The registered manager was responsive to feedback.

The provider made sure there were enough qualified and experienced staff, but they did not always make sure staff received effective support and development.

The provider used a training matrix to monitor training compliance. This demonstrated staff had received training required for their role. However, not all staff had yet received some of the necessary training for supporting people with learning disabilities and autism, although there was a plan in place to rectify this

The provider ensured staff had suitable employment checks undertaken before working in the service. This included identification checks, Disclosure and Barring Service Checks (DBS) and previous employment references. However, in 1 staff file, there was not a full employment history.

The provider employed enough staff which ensured people received their care and support from staff who were familiar with their individual needs, preferences and daily routines.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Areas of the environment were visibly unclean, including bathrooms, doors and walls. Cleaning was performed by staff and there was a cleaning schedule but the cleaning and audits were not effective.Audits in 2026 had highlighted some areas that required improvement, but these had not been actioned. For instance, an infection control audit in April 2026 had highlighted that cleaning fluids were not locked away but they were still not locked away in May 2026. The audit also highlighted uncovered and unlabelled food in the kitchen fridge, but this had not been addressed. This puts people at increased risk of infections.

However, PPE was available to staff and management were responsive to feedback.

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

People’s care records contained conflicting guidance around seizure protocols and when they should be administered PRN (as required) medicines. This put people at risk of receiving too much medicine.
People’s (Medicine Administration Record) MAR charts stated that prescribed medicines such as thickener was to be administered. There were gaps in the recording of administration, meaning that the service could not be assured people had received their required thickener, putting them at increased risk of aspiration and harm.

People’s PRN protocols contained limited guidance for staff as to when to administer paracetamol, and how much people should receive, putting them at increased risk of pain.

The management were unaware of the STOMP principles (Stopping over medication of people with a learning disability and autistic people). This is a national NHS England program with an identified priority, to stop the inappropriate prescribing of psychotropic medications for children, young people and adults. It is important to be aware of these principles and guidelines to improve the lives of the people who live at the service.The provider committed to considering STOMP principles immediately.