Archived: The Chestnuts

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 remained Requires Improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The provider was previously in breach of legal regulations in relation to people’s safe care and treatment in the way people’s medicines were managed safely. Improvements were not found at this assessment, and the provider remained in breach of this regulation. In addition, we found improvements were required about how risks posed to people were managed and mitigated. People were at increased risk of spread of infection and staff were not always prepared for emergencies like a fire.

The provider was previously in breach of the legal regulation of safeguarding in relation to depriving people of their liberty. This was previously reported under the Effective domain. Improvements were found at this assessment and the provider was no longer in breach of this regulation.

This service scored 44 (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 routinely and consistently ensure learning was embedded from accidents and incidents to prevent a recurrence. This meant people were placed at a higher risk of harm. For instance, we found delays in lessons learnt being communicated with staff. One person had been scalded in January 2025, no learning had been cascaded to staff until March 2025 and after our first site visit.

However, staff told us they would report accidents and incidents and relatives told us they were informed when their family member had fallen.

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

We received positive feedback from relatives about referrals to healthcare professionals. We saw when people were admitted to acute hospitals staff at the home kept in contact with the hospital to arrange a safe discharge.

The local community district nursing team visited the home to provide nursing services to people. They advised us they have a good working relationship with the staff.

Systems were in place to ensure information was available for staff to send with people when they were admitted to hospital.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that.

People were not routinely and consistently protected from other people’s level of distress. We found care plans for people who displayed actions which could cause harm to others did not routinely provide staff with information on how best to keep people safe. Where care plans had been updated regarding the risk of harm to people, we found associated risk assessments had not always been updated.

The local authority confirmed they had investigated safeguarding concerns at The Chestnuts and confirmed people had been subject to harm. Themes of harm included unexplained bruising or skin damage, falls and medicine omissions.

However, people told us they felt safe. Comments included “I feel safe here, there is nothing for me to be afraid of” and “Yes, I do feel safe”. This was supported by relatives who told us “Safe yes, I think [person] is safe, she is being looked after” and “Safe oh yes, [person] is definitely safe.”

Staff told us they knew how to raise concerns about people. We observed posters were displayed in the building about how to raise concerns.

The provider did not always work well with people to understand and manage risks.

People were not routinely protected from risk posed to them. We found risk assessments were not updated in a timely manner to ensure staff had up to date information on how to prevent harm to people.

There was guidance for staff on how when risk assessments should be updated. However, we found this did not always occur. For instance, policies and guidance advised falls risk assessments needed to be updated after a fall, however, we found this was not always the case.

Risk assessments and support plans for people who were at risk of choking and had documented incidents of choking were not always updated in a timely manner. One person had choked in January 2025, the support plan had not been updated until March 2025. This meant people were at increased risks of choking as staff told us they used the support plan to guide them on what people needed help with.

We found where risk assessments had been completed these did not consistently reflect the level of risk or clearly advise staff on how to mitigate the risk. For instance, risk assessments completed for malnutrition were not always accurate.

When care plans referred to risk assessments, and stated they had been completed, we found these were not always in place. For instance, one person’s care plan referred to a personal care and mental health risk assessment. We found these had not been completed.

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

We observed the service was not equipped or suitably prepared in the event of a fire. Staff told us they were not confident on what to do in the event of a fire. A fire grab bag did not contain industry recognised items, such as communication aids. Although each person did have a personal emergency evacuation plan, these were not fit for purpose. We asked the provider to make some immediate changes to improve their readiness for a fire.

The Chestnuts had been visited by Buckinghamshire Fire and Rescue service on 9 January 2023, following the visit a letter of fire safety matters was issued. The letter contained 8 recommendations where improvements could be made to maximise fire safety at the home. The provider had completed the required changes.

We observed a large area of flammable waste in the garden of the home. This was close to the main building, we shared these concerns with the Buckinghamshire Fire and Rescue Service. The provider ensured this area had been cleared following our feedback.

We found some improvements had been made in identifying improvements for maintaining a safe environment. For instance, a health and safety audit completed in December 2024 did not identify any remedial actions to improve a safe environment at The Chestnuts, however, a following audit which covered the same topics completed in February 2025, identified over 50 remedial actions needed to improve safe environment at the home.

The provider had systems in place to ensure there were enough qualified, skilled and experienced staff to support people.

People were supported by staff who had been recruited safely. We found pre-employment checks were carried out on all staff prior to a start date being agreed. This included a Disclosure and Barring Service (DBS) check which provided information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

Records showed staff had not always been supported and supervised in line with the provider’s policy, however, staff told us they felt supported.

Systems were in place to ensure each shift had enough staff on duty to support people. However, we received feedback and comments from relatives about the reliance on agency staff. We found although the provider did use a high number of agency staff many had been working in the home for a number of months and some for years and knew people and their care needs.

We received mixed feedback from people and their relatives about staffing levels. Comments included, “Staff numbers vary, it changes from visit to visit, there are always lots of temporary staff which is not ideal, I do see lots of them but the residents generally seem to be happy” and “During the day I think the carer numbers are okay but at night I am not so sure, the call bells are all attached to the walls and if someone falls, it relies on the sensors or mattress alarms for someone to attend but people can be there [on the ground] for ages if they have a fall”. We observed some delay in sensors being responded to when we were at The Chestnuts. We provided feedback to the provider. Other comments included “There’s always enough [staff]” and “There are always three [staff] on at one time”.

We received mixed feedback from staff on how effective communication was between each shift. Some staff told us the handover meetings were useful and other staff told us they found it difficult to know what had happened when they had returned to work following days off.

The provider had systems in place to ensure there were enough qualified, skilled and experienced staff to support people.

People were supported by staff who had been recruited safely. We found pre-employment checks were carried out on all staff prior to a start date being agreed. This included a Disclosure and Barring Service (DBS) check which provided information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

Records showed staff had not always been supported and supervised in line with the provider’s policy, however, staff told us they felt supported.

Systems were in place to ensure each shift had enough staff on duty to support people. However, we received feedback and comments from relatives about the reliance on agency staff. We found although the provider did use a high number of agency staff many had been working in the home for a number of months and some for years and knew people and their care needs.

We received mixed feedback from people and their relatives about staffing levels. Comments included, “Staff numbers vary, it changes from visit to visit, there are always lots of temporary staff which is not ideal, I do see lots of them but the residents generally seem to be happy” and “During the day I think the carer numbers are okay but at night I am not so sure, the call bells are all attached to the walls and if someone falls, it relies on the sensors or mattress alarms for someone to attend but people can be there [on the ground] for ages if they have a fall”. We observed some delay in sensors being responded to when we were at The Chestnuts. We provided feedback to the provider. Other comments included “There’s always enough [staff]” and “There are always three [staff] on at one time”.

We received mixed feedback from staff on how effective communication was between each shift. Some staff told us the handover meetings were useful and other staff told us they found it difficult to know what had happened when they had returned to work following days off.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Our observations and records showed people were having their medicines administered as prescribed. However, the handwritten medicines administration records (MAR) were not always checked and signed by two members of staff. This meant if there was an error made in writing the MAR, this would not be identified.

We found allergies were not always recorded on the MAR, putting people at risk of harm. Medicines were stored securely. However, staff did not always record the date of opening for liquid medicines.

Staff did not check and record the temperature of the medicine refrigerator. This meant liquid medicines and medicines stored in the refrigerator may not be effective as these were not stored as per the manufacturer’s instructions.

Some people were prescribed medicines such as pain relief and anxiolytics (anxiolytics are often used to reduce anxiety for people) to be administered on a when required basis. However, protocols or information in care plans was not always in place to ensure these medicines were given consistently. The care plans for medicines were not always person-centred. We found two people who were prescribed medicine for seizures had no care plans in place on how staff would support them if they had a seizure, putting them at risk of harm.

Staff received training and were competency assessed to handle medicines safely. Staff carried out audits to identify gaps and make improvements. However, the audits failed to identify the concerns for medicines management we found during the inspection.

Medicine reviews were carried out by the local GP. There was a process to report and investigate errors and incidents.