Chater Lodge

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 good. At this assessment the rating has changed to 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.

This service scored 59 (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 demonstrated a commitment to learning and improvement. They gave examples of learning from previous events. For example, following a recent incident where a person had left the service without support, the registered manager had implemented more robust pre-admission assessments to specifically identify this risk before people began to use the service. Additionally, the registered manager had introduced new processes around signing in and out of the premises to mitigate the risk of further incidents. Staff monitored and recorded incidents and daily meetings helped to ensure learning was cascaded to staff. A relative told us, “Staff always telephone if [Name] has had a fall or has been unwell.”

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They aimed to provide continuity of care, including when people moved between different services. A person told us, “I found the transition from home to here very difficult but I was able to bring some of my things and furniture with me which made things a little easier.” A relative told us, “There were a lot of assessments and meetings to support [Name] to transition from short to permanent stay. However, there has been little in the way of review to ensure the transition has been successful.” The provider had systems and processes in place to support admissions and transfers of care. The provider had identified processes needed to be more robust following a recent incident and these had been developed to include more detail. Staff were informed of people’s needs through care plans and handovers.

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. People told us they felt safe in the service and this was confirmed by relatives. A person told us, “I’m looked after well, I’ve no complaints.” Staff received safeguarding training. They understood how to recognise and report poor care and abuse in line with the provider’s policies and procedures. A staff member told us, “If I saw something untoward I would ask someone to intervene. I would tell them to step aside and stay with them until the manager came. We can always talk to the management team and (Regional) director and keep on going until it gets sorted. We have a whistleblowing team; I can speak to them if I need to.” People’s care plans included any legally authorised restrictions to their liberty, for example being supervised, which helped to safeguard people from unlawful restrictions.

The provider worked with people to fully understand and manage risks by thinking holistically. However, people’s care plans did not always provide sufficient, personalised guidance to support staff to manage risks. For example, some care plans lacked sufficient detail to support people with complex conditions like Parkinson's disease and epilepsy, increasing the risk of poor care. Additionally, care plans did not always include sufficient guidance around catheter care and people’s specific mobility needs, and were not always updated in a timely way following a change in needs. The provider responded by immediately updating care plans identified at this assessment to include associated risks and planned to review all care plans to add sufficient guidance for staff on how to manage risks.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. However, not all areas of the facilities and premises were well designed and met the needs of the wide range of people who used the service. For example, the first floor was in need of renovation and lacked sufficient stimulation to support people living with progressing dementias. People who walked with purpose were redirected to areas which lacked any meaning or engagement for them. We observed the environment did not present opportunities for people who needed to walk around to ensure this was meaningful. Some items of furniture required replacement, for example, we found a sofa with missing covers and split plastic. A relative told us, “There is a big difference in standard of environment from the ground floor to the first floor. The first floor looks tired and shabby in areas, and the colour scheme is very bland.” There were clear roles and responsibilities for the safe management of facilities, equipment and premises. A staff member told us, “We have routine cleaning and deep cleaning. We know there are some odours upstairs which are difficult to manage as the furnishings aren’t supportive of people’s needs. There is a big difference from downstairs to upstairs.” We raised concerns with the providers’ representative. They told us a full refit and refurbishment was planned for the first floor and plans were being finalised before sharing with people and relatives. We observed a comprehensive system to ensure routine and specific safety checks were completed.

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. A person told us, “I am happy with the ‘average’ response time from staff. I recognise that there are busy times. If I have had to wait longer, it hasn’t caused me a problem.” Overall staff were recruited safely. Appropriate checks were completed on new applicants to ensure they were suitable for the role. However, we found inconsistencies in staff recruitment records relating to gaps in previous employment history. These had not been identified through quality assurance processes. The registered manager addressed this following our inspection visit. Staff received an induction and told us they were supported in their roles.

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. There was an effective approach to assessing and managing the risk of infection, which is in line with current relevant national guidance and standards. We saw evidence of good communication with external professionals and evidence advice was sought and acted upon when required. There was a good supply of personal protective equipment available to staff and housekeeping staff followed robust schedules and processes.

People’s medicines were overall managed safely and they received their medicines as prescribed. However, we found some medicine records required further development. People could take their own medicines if they had been assessed as safe to do so. However, there was no information recorded on how people liked to take their medicines. Person centred guidance was in place to support people to have their ‘when required’ medicines and outcomes from this were documented to review effectiveness. However, some care plans we reviewed lacked sufficient information about people’s medical conditions and the medicines they were taking, for staff to support people with their complex needs. For example, we saw that one person was taking a medicine which required regular blood tests, and this was not mentioned in the care plan. Risk assessments were not always fully completed, and any actions required from these were not detailed in the care plans. For example, where people were prescribed emollients, there was no information for staff on how they could support people to reduce the fire risks. Following our inspection and feedback, the service reviewed peoples care plans, risk assessments and medicines profiles and made the necessary improvements.  Systems were in place to safely administer and store medicines. Staff felt supported in administering medicines and they had received regular medicines training and competency checks.