Chesford Grange 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

Safe

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 Good. This meant people were safe and protected from avoidable harm.

The provider was previously in breach of the legal regulation in relation to safe care and treatment and safeguarding people from abuse. Enough Improvements was found at this assessment, and the provider was no longer in breach of theses legal regulation.

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.

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.

Relatives told us they knew how to raise concerns or make a complaint. One relative told us, “When my [family member] had a fall, the [registered manager] investigated it. They told me the outcome of the investigation and explained what had been put in place and how things would be managed differently in the future. The [registered manager] also said any lessons learned would be shared with staff.”

Staff told us learning was shared through handovers, flash meetings, training, and management walkarounds. One staff member told us. “I understand how to raise concerns and have the confidence to do so and how to follow them up.”

Incidents were reported and reviewed, and staff told us learning was used to improve practice and reduce the risk of reoccurrence. There was evidence that learning from incidents led to improvements. For example, following falls, the provider introduced a renewed focus on call bell response times and was implementing a new system linked to staff devices. This system enabled staff to see who had responded to a call bell, reducing the risk of duplication or missed responses. This improved clarity of responsibility and helped reduce delays in care.

The registered manager completed regular walkarounds, observations and competency checks, including asking staff questions to assess their knowledge and understanding. Staff demonstrated awareness of key risks, including how to support people at risk of falls.

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 and relatives told us they felt safe. One person said, “Staff are kind. I do feel safe here.” A relative told us, “It’s fantastic here. [Family member] feels safe. I feel reassured and I don’t have to worry about [family member].”

Professionals spoke positively about the service. One professional told us, “Staff know residents extremely well. Staff are excellent at highlighting any changes or issues with residents and are able to contact the appropriate professionals promptly. The service works with you to support people very well. Discussions are thorough, and we are always able to come up with a solution that is tailored to each individual and their personal needs.”

Since the last inspection, the management team had made improvements to the way people's health needs were monitored and managed. Systems were in place to support continuity of care, with clear processes for monitoring people's health and escalating concerns. Records showed staff supported people with areas such as oral healthcare and understood the actions to take if concerns were identified, including weight loss, declining personal care or changes in health needs. Where people were living with health conditions such as diabetes, there was evidence these were managed safely. Blood glucose levels were monitored in line with guidance where required, and staff recorded these appropriately. This demonstrated staff understood how to escalate concerns and seek further 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 received safeguarding training and demonstrated a clear understanding of their responsibilities. Staff were able to explain how they would raise concerns. One staff member told us, “We have all had safeguarding training. If there was a concern, I would escalate it to the registered and deputy manager. I am also aware if actions were not taken, I could contact the local safeguarding team and CQC.”

Safeguarding concerns were referred appropriately to the local authority safeguarding team and investigated in line with local procedures.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. This can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found where people lacked capacity, the provider completed MCA assessments and they were decision‑specific. The provider also applied and monitored DoLS authorisations in a timely and consistent way, ensuring any conditions were checked and incorporated into care plans.

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.

People were supported to make their own choices, including where these involved potential risks. For example, one person with capacity was identified as being at risk after being placed on a modified diet and had stopped eating. Staff explained how they worked closely with the person, alongside the chef, to identify foods they could eat safely. They spent time encouraging the person to eat, trying different approaches based on what they liked. The person expressed a preference to remain in their room at mealtimes. Staff respected this choice while ensuring their safety needs were met. Regular checks were carried out to confirm the person was positioned correctly and eating safely. There had been input from the Speech and Language Therapy (SALT) team, and staff had received additional face‑to‑face training to support safe eating practices. The person’s family were also involved in care planning and ongoing decisions about managing risk.

People had detailed risk assessments in place to guide staff on how to support people safely and appropriately.

Risks were managed in a way that promoted people’s independence, choice and control.

The provider did not always identify and control potential risks within the care environment. However, they ensured equipment and technology supported the delivery of safe care.

During the inspection, communal areas were extremely hot. A lounge window was broken and could not be opened, which restricted ventilation, and there were limited fans available. This resulted in an uncomfortable environment for people and staff. The provider took immediate action on the day of the inspection by repairing the window and introducing portable air conditioning units.

People and their relatives told us the home was clean and well maintained. One relative said, “My [family member's] room is always clean and tidy. I have no concerns.”

Routine health and safety checks, including water temperature and fire safety monitoring, were completed regularly. External health and safety inspections had also been undertaken, and the home met relevant building requirements.

Systems were in place to support a safe and clean environment. However, the overheating of communal areas demonstrated that some environmental risks were not always identified and managed proactively, despite prompt action being taken once concerns were identified.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The registered manager determined staffing levels in line with people’s individual support needs. Feedback from relatives about staffing levels was mixed. Some relatives felt there were enough staff available. One relative told us, “When I visit, they always have enough staff,” while another said, “There always seems to be plenty of staff around.” However, another relative told us, “They may not have enough staff, but what staff they have are marvellous. [Family member] cannot use the call bell. They could do with more staff, but they run a brilliant team. [Family member] is doubly incontinent, but they always deal with this straight away.”

Staff received a comprehensive induction and regular training, including face-to-face training, to ensure they had the skills and knowledge to support people safely and effectively. Staff spoke positively about the training provided and the impact it had on their practice. One staff member told us, “We receive online and face-to-face training, which gives us more knowledge and confidence in our role.”

Staff were recruited safely. The provider had effective recruitment procedures in place, which included completing the necessary pre-employment checks.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

People and relatives told us the environment was also clean and tidy. One relative told us, “The home is immaculate. [Family member] clothes are always hung up and ironed although I also look after these. There is no smell in the home. [Family member] is always clean-shaven and [family member] hair is tidy.”

Staff showed a good understanding of infection prevention and control and were seen following good hygiene practices during the inspection. We checked pressure cushions and slings, as during the previously inspection these had been found to be soiled. On this inspection, there were no concerns and all equipment checked was clean and free from odour.

There were systems in place to support infection prevention and control. During the inspection, the home was clean, well maintained and free from unpleasant odours. Cleaning schedules were in place and were being followed, which was confirmed through records and our observations.

The provider always made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff always involved people in planning, including when changes happened.

Since the last inspection, improvements had been made to medicines management. The management team had taken a more active lead, with a focus on strengthening practice and returning to ‘back to basics’ to ensure staff followed correct procedures. This included reinforcing staff responsibilities through supervision, where medicines management was discussed regularly to support accountability and consistency.

Staff had received medicines training and competency assessments and demonstrated confidence in their practice, helping to ensure people received their medicines as prescribed. As a result, medicines were managed safely, with systems in place to support staff to administer them appropriately.

There were clear arrangements for ordering, storing and disposing of medicines safely. We saw that medicines were kept securely, with temperature checks completed to confirm they were stored within the required range. Records showed that regular audits were carried out, and where any issues were identified, appropriate action was taken. We reviewed medicines administration records and found these were completed accurately, with no unexplained gaps. During a medicines round, staff were observed following safe practices, including checking people before administering medicines and documenting administration correctly. Where medicines needed to be given at specific times, this was followed in line with prescribing guidance. For people who required covert medicines, there were clear care plans in place which reflected current guidance and legislation.

Staff worked well with external professionals, including the GP and pharmacy team, to support safe practice. A new paperless system had also been introduced, which helped to improve recording and oversight of medicines. Overall, systems supported safe medicines management and provided oversight to help identify and address any risks.