Charnwood Oaks Nursing Home

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 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.

This service scored 34 (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 did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

We found evidence the service had failed to follow advice from the Local Authority and infection prevention and control (IPC) professionals. As a result, the service had remained in outbreak for several week. This lack of timely, effective action meant risks were not reduced quickly enough and problems were allowed to persist. Where concerns had been identified previously, improvement was not robustly embedded or sustained. This meant the service did not learn effectively from issues and did not consistently prevent repeat failures, which placed people at continued risk of harm.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

We found the service had failed to ensure it had sufficient quantities of medicines when people were admitted, which contributed to the service running out of medicines. For example, a person had moved into the service, and leaders had failed to ensure they had adequate stocks of the person’s epilepsy medicine, and as a result, the person missed 2 doses of medicine. This resulted in the person experiencing epileptic seizures, which, prior to this, had been controlled. The registered manager told us the provider’s policy was to ensure people moved in with at least 4 weeks’ worth of medicine. However, this rarely happened due to a number of external factors. The provider had failed to ensure timely escalation had occurred until medicine stocks were running critically low, and this meant a person suffered harm as a result of this delay.

We reviewed another admission to the service and identified issues with medicine stock for the second person also.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that.

Some staff could describe the safeguarding training they had received and appropriate actions they would take if they had concerns. One staff member said, “Staff all have safeguarding training online, quick reading materials and '60 second read' guidance is always available for refreshers, good as it acts as a reminder. Staff escalate safeguarding concerns.”

DoLS authorisations were in place for people who needed them, and the service could evidence that conditions attached to authorisations were being met. However, safeguarding systems did not consistently assure protection from avoidable harm because wider safety systems, staffing pressures and failures in timely response meant people were left distressed and without support, and risks were not always assessed and managed effectively.

The registered manager understood their duty to report safeguarding concerns to the Local Authority safeguarding team, and we saw evidence appropriate referrals had been made. However, we found a lack of evidence to demonstrate these incidents had always been robustly investigated by the leadership team, especially around unexplained bruising.

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

We found significant shortfalls in risk management for people known to display physical aggression. Positive Behaviour Support (PBS) plans lacked sufficient detail to guide staff, and ABC charts did not contain the level of information needed to enable meaningful review of incidents and to reduce the likelihood of reoccurrence. The impact of this was evidenced by staff being placed at risk, including two staff members being punched, and the lack of guidance increased the likelihood of distress escalating and harm occurring.

Risk management was also weak in other areas. Where a person was known to become distressed during hoist transfers, staff did not have sufficiently detailed guidance about how to manage this safely and reduce distress. Clinical monitoring also lacked important baseline information. For example, staff were recording blood pressure readings for 1 person without baseline statistics to support interpretation and escalation. Pressure ulcer information was not consistently clear and accurate, and repositioning records did not always demonstrate people had been repositioned in line with their care plan which could have resulted in serious damage to their skin.

Diabetes risks were not managed safely. We identified nursing staff omitting insulin on multiple occasions without specialist medical authorisation from the person’s GP or diabetic specialist nurse. Diabetic care plans failed to clearly guide nurses or care staff in how to safely support the person with their diabetes and clear steps staff should take in the event a person was experiencing low or high blood sugar readings. This could have resulted in serious damage to their health. One person who had experienced low blood sugar readings was unable to be administered their prescribed Glucogel (a fast acting medicine to raise blood sugars for people with diabetes) as the service had run out of stock. We shared our urgent concerns with leaders and they implemented improved care plans and guidance for staff, as well as kits to help staff manage people’s low blood sugar readings.

These failures meant risks were not consistently managed in a way that kept people safe.

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.

Cleanliness and equipment safety did not provide consistent assurance. We found concerns with mattress and equipment cleanliness, perished pressure cushions, and bathrooms being used as storerooms. Slide sheets were ripped or damaged, exposed porous wood was identified in ensuite bathrooms, along with rust on shower chairs. These issues increased infection and safety risks and meant the environment did not consistently support safe care and had not been identified prior to inspectors reviewing equipment during the inspection.

The environment had some positive features which supported a homely feel, including bedroom doors designed to look like house front doors and corridors set out like a street with plants, lamps and brick‑style walls.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

Staff and relatives raised significant concerns about staffing levels, particularly at night, and described that staffing pressures affected whether people’s needs were met. Staff described being unable to respond to people calling out because they were allocated to one‑to‑one supervision and could not leave that task. One staff member told us, “I can hear residents calling out for up to 40 minutes, but I'm on 1 to 1 so can’t go to the person.” Staff also described using activity staff to watch people due to low staffing numbers. A staff member explained, “Some days there are not enough staff on the unit. Sometimes we make use of activity staff to watch people.”

Relatives described long waits for call bells to be answered, sometimes reported up to 45 minutes, and raised concerns about night care being inconsistent and sometimes rough or unreliable. A relative said, “[Family member] had a call bell, but it was useless as they often had to wait 45 minutes or more for someone to attend to them.” Another relative echoed this and explained, “I used the call bell once when I was with [family member] to get help. It took the carers 45 minutes to see to them.” A staff member stated, “The night staff [recently] said one of the units only had 1 night staff [on duty].”

Feedback about some staff was poor, and relatives did not feel all staff had received adequate training to display competency when working.

We inspected staff records and found staff had been recruited safely.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We found cleanliness concerns relating to mattresses and equipment and concerns about the standard of cleaning and task completion, including where night staff had additional cleaning duties but the cleanliness of communal areas and equipment remained substandard. Staff described that communication during a recent diarrhoea and vomiting outbreak was not timely, with staff not being informed until after they arrived at work. We also identified concerns about stock and availability of protective equipment, including limited glove sizes observed in one area. These shortfalls meant the provider could not be assured that IPC practices were robust and consistently maintained to reduce the spread of infection and protect people.

One relative was asked whether they felt the service was clean. They told us, “It is clean to a point but not always. The floor is often very sticky. I have found soiled things in [family member’s] room. Other relatives told us the home was clean when they visited their loved one.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

The service stored medicines securely and access was restricted to authorised staff. However, there was only one medicines storage room, which was not always suitable for the volume of stock held and caused difficulties when deliveries arrived due to limited space. Leaders told us a second medicines storeroom was due to be completed shortly.

We observed medicines being administered safely and with care. Medicines were clearly labelled, including individual insulin pens and nutritional supplements, and medicines with a shortened shelf life after opening were dated appropriately. Time‑critical medicines were generally given on time; for example, one person prescribed Parkinson’s disease medicines received these on time or within 30 minutes of the prescribed time.

However, improvements were needed to ensure medicines were always administered safely and consistently in more complex situations. Where medicines were crushed for administration via a PEG tube, appropriate authorisation was in place, but guidance on how medicines should be administered safely via the PEG tube was not always documented on the electronic MAR (eMAR) or medicine labels. Covert medicines were used for some people and records showed best interest decisions had been made with relevant people involved, in line with the Mental Capacity Act. However, pharmaceutical guidance on how to give covert medicines safely was not always recorded on the eMAR or labels, which increased the risk of inconsistent practice.

The service also needed to strengthen “when required” (PRN) guidance. PRN protocols did not always explain clearly when to administer medicines, how to assess whether they had worked, or what to do next. In one example, a person prescribed a medicine to reduce anxiety had limited written guidance describing what distress looked like for them, and records did not always evidence the outcome after PRN medicines were given.

GP visits took place weekly and included medicines reviews, and the service had an up-to-date medicines policy outlining training and competency checks. Medicine incidents were reported and we were given an example of an error being reviewed with learning identified to reduce the risk of it happening again.