Chacombe Park

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

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 harm. The provider had effective systems for safeguarding, risk management, safe recruitment and medicines management. People told us they felt safe, and staff knew how to raise concerns. Infection prevention and control systems were in place, although some lapses in practice were observed, which were corrected promptly. Records and oversight needed to be strengthened in some areas, such as DoLS tracking and consistency of infection control, but overall people received safe care and support.

This service scored 69 (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. For example, safeguarding referrals were made when required and refresher training was introduced following a mobility incident. One staff member said they had learned to identify “soft signs” of deterioration, such as fatigue or breathlessness, and escalate quickly to nursing staff.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed and monitored. They made sure there was continuity of care, including when people moved between different services. For example, hospital passports and transfer packs were prepared with relevant information such as Medication Administration Record (MAR) charts and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) documentation. A relative told us, “She did have a fall on her very first night here but the Nurse in charge and Manager listened and put things in place to prevent it happening again.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff had received safeguarding training and knew how and when to report concerns. The provider had systems in place to record, report and act on safeguarding issues, and concerns were notified to the local authority and CQC when appropriate. Systems were also being developed to share learning and embed good practice, such as preventing falls, and improving communication with relatives. The provider had applied for Deprivation of Liberty Safeguards (DoLS) where required and followed the conditions imposed. Residents and relatives consistently told us they felt safe, with one resident saying, “Oh yes, I do feel safe, the carers, they are all so helpful.”

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 them to do the things that mattered to them. People were encouraged to be involved in their own risk assessments and were supported to make decisions about how risks were managed in their daily lives. For example, staff explained options clearly and gave people time to decide what worked best for them. Risk assessments covered areas such as mobility, nutrition and skin integrity. Families confirmed they were consulted, and people told us staff respected their choices. For example, staff rearranged furniture in one room to reduce falls risk.

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.

There were systems in place to inspect the building and maintain fire safety. Equipment such as hoists and slings was serviced and fit for use, and bedrails and bumpers had risk assessments in place and were checked regularly. Business continuity plans were in place which covered outbreaks, loss of power, fire and other emergencies.

However, some risks were not always identified or acted on promptly. For example, oxygen signage in one person’s room was too small, portable heaters were in use without risk assessments, and environmental issues such as dirty bins and stagnant water in vases were found. These were resolved quickly once highlighted, but the need for inspectors to point them out showed that systems were not always effective in preventing avoidable risks.Relatives and people told us they felt safe, and one resident said, “Someone always comes when I press the bell.”

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. New staff, including nurses, were recruited safely with appropriate checks in place. Staff received training to meet people’s specific needs, along with refresher courses to keep their knowledge up to date with best practice. Competencies were assessed regularly to make sure staff could carry out their roles safely and confidently. Staff said they felt well supervised and received feedback on their performance, which helped them to develop. People told us that staff were sometimes busy, particularly during admissions or when residents were unwell, but this did not result in care being delayed. Staffing rotas showed shifts were covered without reliance on agency staff, and staff described a supportive team culture.

The provider did not always assess or manage the risk of infection effectively. Although policies and procedures were in place, and staff were observed wearing suitable PPE when required, inspectors identified several lapses in practice which showed infection control systems were not consistently embedded.

During the inspection, dirty bins, sticky en-suite flooring and stagnant water in flower vases were observed. Personal care trolleys were seen being taken into rooms and some bed bumpers required cleaning. In addition, a build-up of clothing was noted in the laundry, which managers explained related to belongings from short-term admissions and people who had sadly passed away. While this was already part of their action plan, it posed a risk to maintaining high standards of cleanliness.

On a positive note, the home appeared free from unpleasant odours, communal areas were generally clean, and housekeeping records showed daily and deep cleans were scheduled and completed. PPE stations were fully stocked, laundry systems were robust, and staff acted promptly when shortfalls were highlighted. The provider also had a rolling programme to replace older carpets.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. Medicines were securely stored in locked cupboards, fridges and controlled drug cabinets, with access restricted to authorised staff. Controlled drugs, which require additional safeguards due to their potential for misuse, were recorded and checked appropriately. Medicines with a limited shelf life, such as liquids and creams, were dated when opened.

MAR charts were completed appropriately, and PRN protocols included reasons for administration and effectiveness. A minor issue was identified in the PRN protocol for end-of-life medication, which was resolved promptly during the inspection, with further guidance given to nursing staff. Medicines were disposed of safely when no longer required, and records of disposal were up to date.

Staff received annual training, and competency checks to ensure safe administration. Monthly audits were completed, and controlled drugs were checked weekly. However, there was no central tracker to monitor GP medication reviews, which limited oversight of when reviews were due. One resident said, “The meds are always done on time, I have to have them four times a day and if one is missed, I certainly notice it,” which reflected the safe and reliable practice observed.