Charnwood Oaks Nursing Home

Ratings

• Overall

  Inadequate

• Safe

  Inadequate

• Effective

  Requires improvement

• Caring

  Inadequate

• Responsive

  Requires improvement

• Well-led

  Inadequate

Our view of the service

Date of assessment: 23 March 2026 to 23 April 2026

This assessment was undertaken following concerns raised during recent stakeholder visits.

Charnwood Oaks Nursing Home is a nursing home which provides nursing and personal care to older people and people with dementia. At the time of the inspection there were 80 people using the service. The service can support up to 84 people. Charnwood Oaks Nursing Home provides accommodation across 2 floors. Each floor is split into 2 units, making 4 units in total. There is a lift to the second floor. Rooms have en-suite facilities and there are communal lounges and enclosed communal gardens.

The inspection identified serious concerns about people’s safety and day-to-day experience. We observed multiple instances where people were distressed or calling out for help and staff did not respond promptly, and we saw people in undignified situations where privacy was not respected. Risk management was not effective, including Positive Behaviour Support (PBS) plans and incident analysis (ABC charts) lacking detail, gaps in clinical oversight and recording (such as pressure care and repositioning evidence), and weaknesses in infection prevention and control, including cleanliness of mattresses and equipment and poor communication during an infection outbreak.

Leadership and governance systems were not robust enough to identify and address risks, and learning was not sustained, including repeated Regulation 12 Safe care and treatment concerns across multiple inspections. There was evidence of a breakdown in communication between care staff and senior leaders, and leaders did not demonstrate effective oversight of people’s needs and clinical risks, including the absence of a clinical risk register.

As a result, the provider is in breach of 3 legal regulations relating to dignity and respect, safe care and treatment and good governance.

We did observe staff to be friendly and welcoming to inspectors, recruitment processes were safe and well organised, and there were pockets of good practice such as secure controlled drugs storage, clear labelling of insulin pens, appropriate escalation to Speech and Language Therapy after choking incidents, and meeting DoLS conditions where these applied. Relatives often spoke positively about day staff and described regular visits from health professionals, limited hospital admissions for many people, and that end‑of‑life wishes had been discussed and recorded for some people. There were also some person-centred touches, such as supporting wishes and goals and thoughtful bereavement gestures for families.

While the service had some strengths and committed staff, urgent and sustained improvement was required to ensure people were treated with dignity, received safe care, and that leaders’ oversight systems would reliably drive improvements.

This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.

People's experience of this service

Some relatives provided positive feedback, particularly about day staff. Most relatives we spoke with said staff generally knew their loved one’s likes and dislikes and tried to treat them as individuals. Relatives told us medical professionals visited regularly and felt the home worked well with external health professionals. Several relatives also told us hospital admissions had been limited, and many people had maintained a healthy weight. End of life wishes had beendiscussed and recorded for some people, and some relatives felt communication was good, although a number said this could be improved.

However, people’s experiences were not consistently positive or safe. During the inspection we observed multiple instances of people becoming distressed or calling out for help without staff responding in a timely way. Some relatives described seeing distressed people left unattended during visits.

Relatives and staff raised concerns about staffing levels, particularly at night, and concerns about call bell response times, sometimes reported to be very prolonged. One relative stated, "I don’t understand why there is a reduced number (of staff) at night - in practice the people don’t know day or night (due to their dementia diagnosis) and with the lack of strong supervisor around, I really think there is a weakness." Relatives also raised concerns about night care being inconsistent, including pad changes and personal care, and described a lack of stimulation for some people. Several relatives said they did not feel involved in care plan reviews, did not know who the manager was, and did not feel they had meaningful opportunities to provide feedback through surveys or other routes.