OSJCT Chestnut Court

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. The last time we rated this key question we rated it good.

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

This service scored 75 (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 positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. There were opportunities for reflection and learning so safety could continually be improved.

The provider understood their responsibilities in relation to Duty of Candour; being open and honest when something unplanned happened. Where incidents involving people had taken place, action had been taken to protect people involved and relatives had been informed. A relative confirmed this had been the case when their family member had been involved in an incident.

The service kept records of some reflective discussions which had led to lessons learnt, although not all reflective discussions had been recorded. Managers told us they would look at ways of capturing all these discussions.

Staff completed health and safety training; they were aware of what may constitute a safety concern and they knew how to report these. Staff received training on safe ways of working, irrespective of their role. There were arrangements to embed good practice. An example of this was the additional training provided to some care staff to strengthen their moving and handling practice.

Daily heads of department meetings were held, where new emerging safety issues and decisions on how these would be addressed, were made. Information pertinent to the wider staff team was then shared with them.

Health and safety checklists were completed on a regular basis and actions from these added to the service’s improvement plan. We reviewed checklists from January 2025 through to May 2025 and there had been no required actions.

The provider had contingency arrangements for unplanned emergency events. In such situations, these arrangements supported joint working with emergency services, commissioners of care and other relevant agencies.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They took steps to maintain continuity of care.

People’s needs were assessed before admission. A recently completed pre-admission assessment recorded all relevant information to help managers determine if the person’s needs could be met at Chestnut Court.

The provider had made changes to how admission decisions were made. This was so a better balance could be achieved between the needs of people already being supported and the needs of people potentially moving to the service.

Staff worked in partnership with care commissioners, people and their relatives, to establish and maintain safe ways of supporting people. In the case of 3 people with complex needs, this had included providing additional care resources and working with specialist health professionals, including family members, to support their needs.

Managers were aware of the risks during a person’s health and care journey. The provider’s policies, procedures and protocols supported safe and effective transitions. This included the sharing of relevant information between the care home, commissioners of care, paramedics and hospital staff. Staff ability to work collaboratively supported continuity of care and reduced the risk of inappropriate placements and transfers.

Staff and specialist healthcare professionals worked together to ensure continuity of care for a person whose needs would possibly require specialist support, in another setting.

There were arrangements to keep staff up to date with changes in people’s health and care needs.

The provider worked with people to help them remain safe. They shared concerns appropriately with health and care partners to find the best way of achieving safe care. Staff concentrated on improving people’s lives, whilst protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

The provider had policies and procedures to safeguard people from abuse and to uphold people’s human rights when in care. Rights which included, respect for private and family life, choice and autonomy. We observed posters on display which explained what safeguarding was and how to report concerns.

There were procedures for addressing any form of abuse, discrimination or poor practice. Staff received training to help them recognise related concerns and how to report these. Staff told us they were aware of these procedures, and they were confident their concerns would be addressed. A member of staff told us they had followed these procedures recently in response to information a person had shared with them.

During the assessment a person shared information with us, which was potentially of a safeguarding nature. They gave us permission to share this with the managers who responded immediately to this so they could be assured any safeguarding concerns were addressed.

The provider ensured safeguarding concerns were reported and shared with relevant agencies, such as the local authority (LA), police and the CQC. A relative said, “[Relative] was involved in an incident at the home and ended up in hospital. The staff were lovely towards [relative], and safeguarding was correctly put in place following the incident.”

Managers present at this assessment were reviewing all records pertaining to authorised Deprivation of Liberty Safeguards (DoLS), including referrals submitted to ensure people were protected against unlawful restrictions to their liberty.

The provider worked with people to understand and manage risks by thinking holistically. The provider had arrangements to help staff support people correctly so their health and care related risks could be safely managed.

Staff were supporting people to manage risks, which included, for example, choking, development of pressure ulcers, falls and seizures. The provider had protocols for staff to follow in the event of a fall or medical emergency.

Prior to the assessment we had been made aware that action in response to 1 incident had not been taken in a timely manner because staff had been unclear on the action they needed to take. The person had not been harmed, and this had resulted in their treatment being altered. However, lessons had been taken from this, and staff had been supported to be clear on the action they should take should a similar incident happen again. Staff had also completed additional training to support this learning.

During the assessment a person fell, and a member of staff involved knew there was a falls protocol but told us they were unsure what action to take. This person received the support they needed, but we fed this back to managers who addressed this with the member of staff. Other staff we spoke with were clear about the falls protocol.

Staff helped people to understand and manage their health-related risks. Staff had discussed with 1 person, the risks associated with declining necessary care. Despite this, the person had continued to decline care and so staff monitored the person’s health so further discussions could be held if the risk increased.

People’s relatives told us staff took action to reduce their family members’ health risks. A relative told us their family member’s risk of falls had been reduced by the introduction of additional staff supervision. Another relative said, “[Name] is at risk of choking but she is on a soft diet, and they manage it well.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Chestnut Court is a purpose-built care home which supported care to older people. Arrangements were in place, so staff were aware of who was entering and leaving the building.

People lived on 4 units, each providing living accommodation with access to outside spaces which were accessible by wheelchair. The design of the care home also supported people who lived with more advanced dementia.

People on 1 unit were observed to have the freedom to walk in and out of an external secure courtyard space. Staff monitored people from a distance and sat with them, offering closer support.

Adapted bathrooms supported people who were less able to bathe independently. The environment was designed to safely support the use of care equipment, such as wheelchairs and hoists. Alarm activated equipment helped staff monitor people whose risks were associated with falls or distressed behaviour, in a less intrusive way.

The provider had a schedule of safety checks and maintenance tasks, which were completed by the in-house maintenance team, who were supported by the provider’s wider estates department, when needed.

The provider had servicing contracts with specialist contractors to ensure the environment, its systems and equipment, remained in working order.

All staff were aware of how to report environmental concerns, and the daily risk meeting provided heads of departments with an opportunity to discuss any new or emerging risks.

Relatives told us the environment was safe. A relative said, “The environment is good, and they have recently had new equipment delivered and it’s all very good.” Another said, “The security is good around the building.”

The provider had taken action to ensure there were enough qualified, skilled and experienced staff, to meet people’s needs. Improvements were being made to ensure staff received effective support, supervision and development.

Relatives feedback on staffing was mixed. Comments included “There are enough staff but when the demand is high, there are times when they don’t have enough staff” and “They have plenty of staff on her ward [meaning unit].” Feedback from people was also mixed, some people told us staff were available when they needed them, and others told us staff asked them to wait because they were busy. A member of staff said, “We could do with more staff. Staff can be very thin on the ground” and another member of staff referred to a shortness of cleaners.

Whilst feedback was mixed we observed a busy service where all staff teams were working calmly together to meet people’s needs. Managers told us what actions they took to ensure the service was appropriately staffed and they were confident there were sufficient staff to meet people’s needs.

Managers regularly reviewed people’s dependency levels, using a dependency and staffing tool as a guide. However, if people required additional care (one to one support) they looked at ways of providing this. In 1 person’s case, the provider was supporting the cost of this as it was needed before formal funding for this was agreed. Daily staffing was reviewed to ensure the right numbers and right skills were in the right places. Changes had been made to how decisions were made about new admissions to ensure a balance was maintained between existing people’s needs, potential new needs and staffing numbers.

Staff recruitment records showed appropriate checks had been completed prior to employment.

Staff received relevant training and were supported to remain updated. Some staff supervision sessions had been delayed, and managers were addressing this. Staff told us the support available to them had improved.

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.

The provider had processes to assess and manage risks associated with infections. Managers were aware of who to report infectious outbreaks to and the provider had processes which were implemented in such situations. A relative whose family member had been in the home during an infection outbreak said, “There was an outbreak, and they did keep us updated. They isolated it by units.”

All staff had received infection, prevention and control training and understood their responsibilities in relation to this. The provider ensured staff had access to personal protective equipment (PPE) and we observed this to be plentiful and safely stored on all units. Staff knew when to put PPE on and how to discard it correctly.

We observed staff wearing PPE when supporting people with their personal care and when supporting people with their food. We observed staff adhering to safe food hygiene practices when serving people’s food. We also observed staff using antibacterial hand gel or washing their hands before and after tasks.

Housekeeping staff kept the environment clean by following the provider’s cleaning schedules. We observed arrangements for the segregation of soiled laundry from non-soiled laundry and systems in the laundry ensured laundry was handled and washed in such a way which reduced the spread of infection.

People were supported to participate in annual Flu and COVID-19 vaccination programmes. Staff were aware of the signs and symptoms which may indicate someone had an infection and arrangements were made to initially isolate the person and support an early referral to a doctor.

Relatives spoke positively about the cleanliness of the environment. A relative said, “The home is clean, and it does smell nice. I do see staff wearing PPE.”

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

Our observations and the records we checked showed people received their medicines as prescribed. Medicines, including controlled drugs, were stored securely and at the required temperatures.

Some people were prescribed medicines for pain relief and constipation, among other conditions, to be administered on a when-required basis. Protocols were in place to help staff give these medicines consistently. One person told us they were prescribed regular pain relief, but they knew they were also prescribed a stronger pain relief, and they could ask for this if they needed it.

Medicine care plans were in place for staff to understand and support people’s health needs. However, for one person who experienced seizures and who had been prescribed rescue medicine, their care plan had not been updated. Managers took immediate action, and this care plan was updated to reflect the new treatment and provide clear guidance on how and when to administer this.

Staff received training and their competency assessed to handle medicines safely. Staff carried out audits to identify gaps in practice and process and to make improvements.

There was a medicine policy and processes to report and investigate any medicines related incidents and errors.

Relatives feedback on medicines was positive with the majority commenting that their family member received their medicines correctly and on time.