Welcome House - 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

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, particularly in relation to accidents and incidents, infection control and medicines. They were also in breach of regulations in relation to staffing levels, failure to submit notifications of incidents. and safeguarding service users from abuse.

This service scored 28 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The registered manager did not always have a proactive and positive culture of safety. Lessons were not always learnt to continually identify and embed good practice.

Although the registered manager recorded accidents and incidents, including descriptions and actions taken, incidents continued to occur because there was no robust follow-up to ensure staff learned from them. The registered manager confirmed they did not carry out any analysis of accidents and incidents to look for trends, themes or triggers. This meant they and staff were not always able to learn from incidents occurring in the service.

For example, one person frequently became distressed and attempted to harm others. Despite this pattern, the recorded action was simply that staff should ensure the person was not left alone when awake during the day. However, incidents persisted, and records showed occasions when the person was left unsupervised. On the day of inspection, one inspector spent 15 minutes talking to this person upstairs without any staff present.

This demonstrated the registered manager had failed to implement and monitor agreed safety measures, putting people at ongoing risk of harm.

The registered manager did not manage or monitor people’s safety when people moved between different services.

One person had moved into the service several months ago. Although they had visited the service once beforehand, other people living there told us they had not been invited to take part in the decision for them to move in, and there was no evidence any further consideration had been given to whether people would be happy living together. As a result, some residents told us they felt, “uncomfortable” in their own home as the new person often became distressed and agitated, which disrupted the household. On our second visit to the service, the registered manager told us this person had been given notice and would be moving out in September. This demonstrated that the assessment process was not sufficiently robust to ensure that people’s needs could be met prior to them moving into the service. Although the registered manager told us, “We were not told everything (by the social worker) and when I went to assess [the person] they were calm. If we had known what we do now….”

A second person was noted as preferring it when other people were not around, as they did not like to be around many people. And yet, they lived in a service where a further 13 people resided. Although they visited the day before they moved in and records state, ‘it went well’ it is clear from the person’s care plan they do no not like to be with others.

The registered manager did not work well with people to understand what being safe meant to them or protect their right to live in safety, free from abuse or avoidable harm. The registered manager did not share concerns quickly and appropriately. We asked the registered manager if they had reported any of the incidents that had happened this year to the local safeguarding team. They told us, “I tell KCC (Kent County Council) about them, but I don’t do a referral. If there was a major incident I would inform CQC.” This demonstrated the registered manager’s lack of understanding on how to recognise abuse and how to report it.

We reviewed the service’s accident and incident records from 11 February 2025 to the first day of inspection. Fourteen incidents were recorded, 7 of which met the threshold for safeguarding referrals. However, these had not been reported to the local authority safeguarding team or the CQC, as required. As a result, the registered manager and provider could not be assured that people were safe living in the service.

Staff did understand what constituted safeguarding and reported incidents internally but there was a lack of robust systems and processes in place to ensure these were escalated appropriately. They were able to identify concerns, with one staff member telling us, “It can be about people’s changing behaviour, isolation, cuts and bruises, etc. I am comfortable (if I did identify something) the manager would do something about it. If nothing is done, I would speak to CQC.” Yet, although staff felt this, there was no evidence that concerns had been raised with the appropriate teams.

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

The registered manager and staff mostly worked with people to understand and manage risks. One person told us, “I feel fairly safe.” A second said, “I feel safe. I think it’s because of the staff.”

Documentation relating to people’s risks had improved since our last inspection and it was evident staff knew people well. We found clear guidance for staff on how to manage each person’s individual risks. For example, for people who experienced seizures, staff were provided with step-by-step instructions on how to respond and when to call the emergency services. For people at risk of self-neglect, care plans included sensitive and personalised information on the most effective ways to support or encourage them to accept help with personal care. Where people smoked, they were encouraged to give their cigarettes and lighter to staff at night and to participate in regular fire drills. There was a dedicated smoking area outside so people did not smoke indoors.

However, although these improvements were in place to support risk management through guidance and direction for staff, the registered manager had not fully considered the potential risks to people arising from some people’s anxiety and distress.

The registered manager did not always detect and control potential risks in the environment.

Although the home provided suitable individual and communal spaces for people, the registered manager had not fully considered safety in relation to the garden. Outside on our first visit, we observed a disused washing machine, a wooden pallet and broken chairs. A metal panel with sharp edges was placed on top of the washing machine. While no one was recorded as being at risk of self-harming, the presence of these hazards posed potential risks, particularly as people were living with mental health conditions. When we went to the service on our second visit we found the garden had been tidied up as the provider’s quality assurance manager had identified we had concerns about it and had fed this back to the registered manager.

Other elements of the service were safe. For example, regular fire drills were carried out with the involvement of everyone living at the service, fire safety checks were completed, electrical checks carried out, and equipment such as the bath hoist was serviced regularly.

The registered manager did not always make sure there were enough qualified, skilled and experienced staff on duty each day, although staff told us they felt there were enough of them.

People told us they would like to go out more but they were restricted because of the staffing levels. One person said, “I went out yesterday, so I won’t go out today because there are not enough staff.” Another told us, “I would like to go out more.” Other people said they could not go out every day because of the staffing levels. There were 4 staff on duty each day to care for 13 people, one of whom required 1 to 1 staffing throughout the day and 2 to1 staffing when going out. It meant that many of the external outings for people were generally organised as a group as there were insufficient staff to accompany people individually. On our second visit to the service, 6 people had gone out together, with 2 staff.

Staff said they received good training. A staff member said, “The training is good. It’s mainly on DVD. We do the Care Certificate (an identified set of standards for health and social care professionals), we do competency assessments for medicines.”

If staff needed more training, they redid modules and in addition to training, staff had the opportunity to meet with their line manager on 1 to 1 basis through supervision. Staff told us they found this useful.

Staff were recruited through a robust process which included them providing evidence of their performance in their last role, their right to work in the UK and their fitness for the role. Prospective staff also went through a Disclosure and Barring Service check to help ensure they were suitable to work at this type of service.

The registered manager did not assess or manage the risk of infection.

On our first visit the service was not clean and there was an unpleasant smell in parts. Touchpoints around light switches, door handles and handrails needed cleaning and there was ingrained dirty marks on doors and walls. The walls in one person’s room were covered in stains and splashes and their sink was not clean.

There were areas which created a trap for bacteria such as a cracked bathroom window, missing bath tap cap, chipped bath enamel and toilet which required de-scaling. The carpet in the hall downstairs was thick with dirt on the steps and sticky and there was also a similar patch on the carpet upstairs. The laundry room sink was also very dirty.

Cleaning schedules for the service were signed as being up to date, these included stating touchpoints had been cleaned. However, the bathroom schedules had not been signed since 7 August 2025. We asked the senior staff member for up-to-date schedules but they were not found.

On our second visit, the registered manager told us, “I have deep cleaned the house since your visit.” They stated that the cleanliness issues had been identified during their monthly walkaround audit. However, on review we noted that this audit was completed on 4 August 2025, before our first visit to the service on 12 August 2025. We also reviewed the July audit, which raised no concerns about cleanliness. Although we noted the provider’s quality assurance manager had identified some concerns in their July audit, these had not been actioned. This highlighted a lack of robustness in the infection control audit process.

The registered manager did not make sure that staff followed best practice in relation to medicines management.

Medicines were stored safely however staff checked the temperature of the medicine cabinet in each person’s room in the morning only, and we read on days the temperature was close to 25 degrees. This meant that staff would not know if the temperature had risen further at the hottest part of the day as they were not rechecking it. Despite discussing this with staff, on our second visit to the service, we found staff had not introduced a second temperature check of the cabinets.

There was no book for medicines being returned. A medicine returns book is crucial for maintaining accurate records of returned or expired medications, ensuring proper disposal.

Records relating to medicines were not accurate which meant the registered manager could not be assured people were receiving the medicines they required. One person’s medicine administration record (MAR) was handwritten and incorrect in places and one medicine was not clearly marked on the MAR, although staff amended this during the inspection. We carried out a stock count of this medicine and there were 82 in stock, however the records showed there should have been 56. The senior staff member said the discrepancy was due to the old stock not being returned at the end of the last month. However without a return’s book it was not possible to check the accuracy of this.

The ‘as and when’ (PRN) protocol for one person did not include information in line with NICE guidance. There was no information on what the medicine was expected to do and the minimum time between doses if the first dose had not worked. PRN medicines were being given regularly, rather than just as and when, and on one occasion a PRN was administered 4 times during the day, when the maximum dosage was 3 tablets in a day.

People’s medicine folders were untidy and not well maintained. One person was prescribed a pain patch. This was administered once a week and needed to be placed on a different part of their body each time. Although staff held a body map which showed where they had placed the pain patch each week, which was good practice, we found that although June and July’s records were in the person’s folder, there was nothing after that until 25 August 2025 meaning there was no record for the first 3 weeks of August. Staff told us initially that the form had been archived and they would look for it, however later a staff member found it in amongst the person’s daily care notes which were held in a totally different folder in a different room. Holding accurate, well-maintained records in relation to a person’s medicines is important to ensure that people were receiving safe care.

Only suitably trained and competency-assessed staff administered medicines to people. We checked the records for all staff and found they had either recently completed medicine refresher training, or had been competency checked by the registered manager (who was train the trainer in medication).