Chester House Care 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 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.

The provider was in breach of the legal regulations in relation to safe care and treatment and the premises.

This service scored 44 (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 always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

We were not assured all accidents, incidents and safeguardings were robustly recorded. Records showed some consideration had been given to prevent future risks; however, we found these preventative measures were not reflected in care plans or actions we observed. For example, one person had previously left the home unseen on 2 occasions; there was no robust care plan in place to mitigate future risks, and we found the building was not secured. We saw no evidence of the use of root cause analysis or regular, detailed analysis of trends and actions taken to mitigate further risks. We were provided with an accident and incident policy; however, this was not effective in staff and management practice.

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 were not assured the management worked effectively with partner agencies to ensure continuity of care and was aware of the need to manage safety between services. On the first day of our inspection, we found a new person had come to live at the home. However, after 2 weeks, we found no assessment of needs had been carried out and there was no new care plan or risk management in place. The only information available to staff was from the local authority; however, a robust, person-centred assessment was required to ensure the person’s needs were safely and effectively met in their new home.

We found there was no formal staff handovers where information was shared between staff in relation to people’s immediate care needs. Staff handovers were verbal, short and not recorded to enable a review of what was discussed and to maintain oversight.

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. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Theproviderdid not always share concerns quickly and appropriately.

We were not assured that appropriate actions were always taken to safeguard people when incidents had occurred at the home. Families were generally positive about the care people received, and most people told us they felt safe living at the home.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found some capacity assessments were in place; however, the ones we reviewed were generally not decision specific and we were not assured everyone who was subject to restrictions had been assessed to check if they required a DoLS.

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.

Most people had individual care plans and risk assessments in place; however, these were not always reflective of immediate needs and did not demonstrate that people or families had been involved in developing plans of care and decisions about how risk could be managed.

We found concerns relating to 3 people in relation to the risk management of their high risk of falling and the use of high risk medicines to thin the blood. We were not assured that one person with a skin infection was having their condition safely managed. We saw no evidence one person’s use of bed rails had been appropriately assessed and routinely checked to ensure their safe use; we signposted the management to published guidance. Additionally, we found concerns with other people’s individual risks around hydration, safe eating and distress. However, we found no-one had experienced significant harm as a result of these omissions. There were several people at the home who experienced distress due to their conditions; we were not assured that staff had the detailed, person-centred guidance and specific training to ensure staff were able to effectively respond to an individual’s distressed behaviour. Personal Emergency Evacuation Plans (PEEPs) were in individual care plans; however, this meant they were not readily available in the event of an emergency. We raised our concerns and the management put this in place at the end of our site visits.

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.

We found concerns in relation to the safety of the environment. We were not assured about fire safety, cleanliness, and the security of the building.

People had access to areas that may be unsafe. The laundry and cupboards were unlocked and contained items that may pose a risk to people, and access from the garden to the road was not secure. We reported access to the road immediately and the management provided a basic padlock for the gate; however, this action created a fire risk. We found wardrobes were not attached to walls creating a topple risk. Some radiator covers were not attached to walls, and some hot pipes were not covered. Emergency pull cords were not positioned within published guidelines and window restrictors were either not in place or were in poor condition. These were replaced during the inspection.

We found multiple concerns in relation to fire safety. Fire doors were propped open to allow free access outside for people who smoke, a fire escape route door was locked with a keypad that was not an automatic open. We found alarms sounding in relation to fire doors and the carbon dioxide monitor, and the fire alarm panel was displaying a fault light. One person’s bedroom was the designated fire escape, and we found furniture in front of the fire door. The last Fire Risk Assessment (FRA) was completed in 2024 and included 17 actions to be completed. The management told us all the FRA actions had been completed; however, we saw no evidence the FRA had been reviewed since 2024 or that the required actions had been completed. For example, one high-risk red action related to an immediate action to prevent people smoking in their rooms; however, we observed cigarettes in one person’s room, 2 people with lighters and saw an incident report from June 2026 where a person was smoking in their bedroom.

We reported all our concerns about the home still being unsafe to the management, and they arranged for a further FRA to be carried out during our inspection period. We also reported our concerns to the fire service.

Refurbishments of the first floor areas had taken place; however, some people’s bedrooms and communal areas needed further work. Ground floor wash areas and some people’s bedrooms were unclean had malodour. The outside space was unkempt with discarded items and broken garden furniture.

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

We were not assured that staffing levels at the home were sufficient to care for 12 people. We were supplied with rotas; however, these did not always reflect what staff told us and what we observed. There was only one care staff on duty on shift and one staff member sleeping between 8pm and 8am. This meant there was a risk people may not receive timely attention when needed. We received mixed feedback from people, relatives and staff about the staffing levels at the home. One person told us, “I would say there are enough staff. I never have to wait. If I need help, I ask.” However, another person told us, “There aren’t really enough staff here for the people. There is just one on at night for 11 or 12 people. They are good though and they help me.”

The home used mainly permanent staff and therefore, people were supported by staff who knew people well. We found some gaps in safe recruitment checks. Our concerns were shared with the management, and we were advised after the inspection that the outstanding information was now in place. Staff told us they felt well supported and had regular supervisions.

We were provided with a staff training matrix showing courses and dates completed. However, we were not assured of the accuracy of this information as when we requested evidence of this training, this was not produced and evidence that was provided to us demonstrated the courses had been completed after our site visits.

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 multiple concerns in relation to infection prevention and control (IPC), and we found the home was not always clean. There were no cleaning staff in post at the time of our inspection and care staff on duty were given a rota to carry out the cleaning duties in addition to their caring role.

Many areas around the home were unclean, including light pulls, skirtings, walls, doors and door frames and we observed some blown and unclean windows. The ground floor washrooms were particularly unclean and were malodorous. The laundry area had no separate, appropriate hand washing facilities and was used to store dirty mops and buckets. There were no hand washing facilities in the medication room and there was a lack of hand towels, hand sanitiser and hand wash throughout the home. We observed medication pots drying on an unclean towel and some people’s bedrooms and bedding were unclean. There was no hot water feed to the bath on the lower ground floor, and this was therefore, not in use. One person’s room had no window which opened, and this meant the room could not be ventilated.

We observed some people had dirty fingernails and, although records indicated people were being supported to wash, it was not clear these areas of personal care were being closely attended to or that records of personal care were accurate.

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.

People’s allergies were not accurately recorded on medicines administration records as per relevant NICE guidance.

When medicines were given to people, we were not always assured that they were given at the time stated on the medicines records and in accordance with manufacturer’s instructions. For example, if a medicine needed to be given before food it was not clear that this had been followed.

Information to support staff to safely give ‘when required’ medicines was not in place at the time of inspection. There was a risk people might not have got their medicines when they needed them. Once the ‘when required’ medicines had been given, the outcome was not always assessed and recorded which meant it was unclear whether the medicine had been effective.

Care plans did not always have up to date, personalised information about how to support people with their medicines and associated risks. People on high-risk medicines did not have regular risk assessments and reviews to ensure the medicines were safe and effective.

People’s medicines were not always stored at an acceptable temperature in accordance with the service’s medicines policy and manufacturer’s guidance.

We could not be assured from the provider’s policy and information provided regarding staff medicines training and competency was robust or completed by all relevant members of staff.

Whilst medicines audits were completed at regular intervals, these were not always effective in identifying medicines-related issues occurring in the service. For example, we found a handwritten entry on a medicines administration record was not completed in accordance with the medicines policy. We also found another medicines administration record did not accurately reflect how the medicine was being administered.

For the medicines errors that were reported, appropriate action was taken. However, the medicines errors identified during this inspection had not been reported and therefore, we were not assured that governance processes were robust.