Chalkwell Grange

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 inspection we rated this key question requires improvement. At this inspection the rating has changed to Inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in continued breach of legal regulation in relation to safe care and treatment. We found additional breaches in relation to staffing, premises and equipment and notifications of incidents.

This service scored 38 (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 in a timely manner. Lessons were not always learnt to continually identify and embed good practice. The action plans completed following the meetings did not always evidence how issues raised were to be addressed, dates to be achieved, if actions had been resolved or remained outstanding, and there was limited information recorded in the formal record kept of lessons learnt. This limited the ability to learn from incidents and feedback and meant learning from good practice was not always identified or embedded across the service.

Staff were not consistently completing detailed behavioural charts, which meant patterns, triggers and changes in behaviour were not routinely identified or analysed. As a result, opportunities to reflect on practice, share learning, and adapt support were missed. This limited the service’s ability to understand what was working well, what needed improvement, and how care could be better tailored to individual needs

The service had a complaints folder in place, which indicated that no complaints had been received since January 2026. However, a completed monthly compliance visit recorded that a complaint had been received during this period, which had not been documented within the complaints file. This meant that complaints were not always recorded or managed appropriately.

The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always make sure there was continuity of care, including when people moved between different services. We found the manager had not put systems in place to ensure people’s needs could be met safely when being discharged from the service.

The provider cared for people on behalf of the local authority, which had raised significant concerns about the quality and safety of care provided to people. However, on the day of the inspection, the manager and Director of Care told us they did not support anyone placed by the local authority. This demonstrated a lack of management awareness and oversight of commissioning arrangements and raised concerns about the provider’s understanding of who they were providing care for and their responsibilities in relation to those placements.

Feedback from a relative highlighted significant concern about how the service managed a person’s transition when their funding arrangements changed. The relative told us that although they informed the manager on more than one occasion that the person’s funds were reducing and that social services were becoming involved, they felt the manager did not engage constructively or provide appropriate guidance or support. Communication between the service, the family and the local authority was described as poor, with the family reporting they did not receive follow up or updates about alternative placement options within the wider provider group.

The transition was further impacted by short notice given for the move, which the family felt did not take into account their availability or the person’s emotional needs. On the day of the move, the family found the person’s belongings had been packed without their involvement, with items placed in bags in an undignified manner. This included personal and sentimental items, which caused distress to both the person and their relatives. Staff communication about the timing of the move was inconsistent, leading to confusion and upset for the person.

The service did not always ensure people experienced planned, coordinated and person centred transitions, or that systems were in place to support safe and dignified moves between services when circumstances changed.
 

The service did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. The provider did not always share concerns quickly and appropriately. Safeguarding policies and procedures were in place; however, these were not always followed when safeguarding incidents had occurred. Not all safeguarding allegations had been referred to the appropriate authorities in a timely manner. Limited information was being recorded in the investigation reports. Accident and incidents were documented but there was little evidence the service used this information to learn from and prevent a similar accident or incident from occurring in the future.

The manager completed lessons learnt after every safeguarding raised however, the formal record of lessons learnt did not always include meaningful future guidance. Safeguarding checklists were not fully completed, leaving gaps in key evidence such as investigation records, care plan updates, oversight sign off, and correspondence. These omissions reduced assurance that all required safeguarding actions were taken, reviewed, and embedded. This meant staff were not consistently supported to apply learning to reduce the risk of similar incidents occurring.

The manager managers had been raising safeguarding alerts with the local authority; however, there had been occasions whereby safeguarding notifications had not been sent to CQC in a timely manner. Providers must inform CQC of all incidents that affect the health, safety and welfare of people who use services.

People told us they felt safe. Staff understood how to recognise the signs of abuse and could describe the actions they would take to safeguard people. This action included informing other agencies if there were concerns about how the service was responding and what actions were being taken. A staff member told us, “I would report to my manager, and I would escalate to local authority if I needed to.”

Another health professional told us, “I feel the service is safe, caring, and well managed. There is a positive atmosphere within the home, and the team appear committed to supporting residents. Like any service, there is always room for ongoing improvement, but they appear open to feedback and development.”
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 a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found staff practice reflected the principles of the MCA. People were encouraged to make their own decisions, while still minimising risk. Staff understood their roles and responsibilities in relation to the MCA 2005 framework. However, we received feedback from a health professional that there were delays and inaccuracies in the submission of DoLS renewal paperwork. They told us they had to repeatedly chase the service for completed forms and had received documentation containing incorrect dates, despite having already provided the correct information. This had resulted in additional follow up and amendments being required. The health professional told us these issues had arisen since a change in management at the service and had not been experienced previously.
 

The provider did not always work effectively with people and those involved in their care to understand and manage risks. Staff did not always provide care that was consistently safe, supportive, or that enabled people to do the things that mattered to them. Not all risks to people’s safety and wellbeing were adequately assessed, recorded, or detailed clearly enough to guide staff on how risks should be managed and mitigated. For example, there was limited information available to support staff in understanding and responding to a person’s anxiety. As a result, staff did not have a consistent understanding of the person’s needs or how best to provide reassurance and appropriate support.

Systems used to monitor and manage risks were not always accurate or effective. A weights audit was detailed however, contained inaccurate information. People were listed as requiring weekly weight checks; however, the Director of Care confirmed these people did not require weekly weighing. There was also no evidence that weekly weights had been recorded, and this inaccuracy had not been identified. This demonstrated that risks were not always reviewed in collaboration with professionals or people to ensure information was accurate and reflected current needs.

Following the inspection, the support manager completed care plan audits which identified gaps in care planning and risk assessments.

Relatives told us they did not always feel involved in their relatives’ care. Not all relatives had seen or been involved in developing care plans, and they were not always informed about accidents or incidents in a timely manner. Most relatives said they had not been invited to attend care reviews. One relative told us, “I am not aware of any care plan,” while another said, “This care plan was undertaken when [relative] moved in, but there has never been a review since with me.” This lack of involvement limited opportunities for shared decision making and effective risk management.
 

The provider did not always detect and control potential risks in the care home environment and ensured this was adequately maintained so people could live safely.

During the inspection, we identified concerns relating to the safe storage and management of COSHH [Control of Substances Hazardous to Health] substances. On the day of our visit, the COSHH cupboard on the first floor was found unsecured. A cleaning product was in use by the domestic team had not been listed on the service’s COSHH data safety sheet. An opened bottle of bleach was found on the floor of an unlocked ground floor laundry room, posing a risk of accidental access, spillage, or exposure to hazardous substances. This meant people, staff and visitors were not adequately protected from avoidable harm, and the provider could not be assured that risks associated with hazardous substances had been appropriately assessed, managed, and controlled.

Health and safety audits were completed monthly. However, the audits lacked detail and not all information recorded on the audit had any dates for actions to be completed and there were no outcomes recorded. Details of who the actions needed to be completed by were also not recorded.
 

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.Limited information was available on staff files to demonstrate a robust induction had been completed to enable staff to carry out their role and responsibilities effectively. Not all staff received regular support in the form of a supervision. Some staff told us they did not have regular supervisions and this information concurred with the home's supervision records. The shortfalls had been identified during monthly compliance audits; however, no action had been taken to address this.

Following the inspection, the manager completed 2 supervisions however, these did not include meaningful conversation, were incomplete and lacked detail. The service improvement plan stated, ‘new supervision forms to be implemented to include evidence of support that is meaningful and focuses on the person’ and recorded that all supervisions would be completed the first 2 weeks of March. A health professional told us, “Although most staff appear caring, some seem to lack the level of knowledge and training I would expect when working with vulnerable individuals on a daily basis. I believe staff would benefit from additional training, as well as significantly more support from the management to ensure the highest standard of care is consistently provided.”

Following our last inspection, the provider had introduced a staff file audit. Areas for improvement were identified; however, the audit did not include what actions were being taken to address the gaps. The audit had been signed off by the manager. Gaps identified from the previous audits had also not been addressed.

We received mixed feedback regarding staffing levels. Management reported that a staffing deployment tool was used to determine appropriate staffing levels. However, all people using the service, their relatives, and staff we spoke with told us they felt there were insufficient staff to meet people’s needs. A person told us, “There are just not enough staff here. Yesterday there was only 2 members of staff for 22 of us. The money is spent on things like satin servettes instead of staff.” Another person told us, “Staff never can come straight away when I press the buzzer.” A relative told us, “They could do with additional staff. People’s needs are changing in the service so there is now more need for carers than there was before.” Another relative told us, “We collectively raised a complaint about staffing levels with the senior management and owner.” Another relative told us, “The only thing is the level of staffing. When someone is called away or a carer is off sick, this places a strain on those that are left. There is not much tolerance spare in the system. When these issues happen, and they do, you can see it is too thin in staffing.”

A health professional told us, “During the unannounced visit, it was clear there was not enough staff. Staff raised concerns about being overstretched due to low staffing levels. We have also received anonymous concerns regarding low staffing levels.”

Another health professional told us, “On occasions it can be hard to find a carer to assist with manual handling. I do not know if care home is fully staffed. I have had some feedback from patients that they do wait some time when they press call buzzer. On occasions I have had to go and find someone to advise the patient needs some assistance. The staff are caring, although there is sometimes a language barrier with some staff as English is their second language. Our staff have to explain details multiple times before the information is understood, this has also been advised to me by patients that they are unable to understand carers. I have discussed this with the manager and they are aware.”

The provider had a recruitment process in place. The recruitment files we viewed included an application form, details of any gaps in a person’s employment, pre-employment checks such as references from previous employers and disclosure and barring service checks (DBS). This helps employers make safe recruitment choices.
 

The provider did not always 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.
The service experienced an outbreak; however, there was a delay in reporting the event to the relevant authorities. This meant the provider did not act promptly to ensure appropriate oversight, monitoring, and support were in place, which may have limited the effectiveness of the response and assurance that risks to people using the service were being managed appropriately.

The manager carried out daily checks and completed regular Infection prevention and control audits to monitor the cleanliness of the service. However, the audits lacked detail and not all information recorded on the audit had any dates for actions to be completed and there were no outcomes recorded. Details of who the actions needed to be completed by were also not recorded. The audits did not identify the shortfalls found on this assessment.

The service had regular cleaning schedules in place and staff had personal protection equipment (PPE) available for their use. However, we found occasions where staff were not using and or disposing their PPE correctly. The local authority also received concerns in relation to PPE during a recent outbreak.

We received feedback from one health professional. They told us, “We were informed in a timely manner regarding D V outbreak, and advised wearing PPE when visiting, which we did. We have to buzz to access care home, which can be difficult as multiple times we have had to wait a long time for door to be opened, this can delay our care to patients.”

Another health professional told us, “The home only officially informed us of the D V outbreak after I had spoken directly with a staff member and advised the manager to notify others. This delay in communication is concerning, particularly given the vulnerability of residents.”
 

The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. There were systems and processes in place for safe management of medicines however, staff were not always following these. People did not always receive their medicines safely or as prescribed. Where people were prescribed time sensitive medicines to treat Parkinsons disease, an error had been made with the directions for one person which staff had not recognised. This meant the person was not receiving their medicines at the required times to control their symptoms. People receiving pain relief, which must not be given closer together than 4 hours, were sometimes receiving doses too close together placing them at risk of harm. One person’s medicines had been changed. Staff had continued to administer medicines from the current blister pack, using the pharmacy description to pick out the medicines which were still prescribed. This was unsafe practice and not in line with the provider’s policy. This put the person at risk of not receiving their medicines correctly. Medicated patches were not being applied in line with manufacturer’s instructions, which could lead to people experiencing unwanted side effects such as adverse skin reactions and a build-up of the medicines in the skin.

People were not being supplied with medicines safely when they had time away from the service. Staff were secondary dispensing the required medicines into a plastic envelope with a handwritten label. Secondary dispensing removes essential information, increases the risk of administration errors and reduces assurance that medicines are administered safely and as prescribed which puts people at risk of harm.

When required [PRN] medicines were not always managed safely. Not all people had PRN protocols in place. Where protocols existed, some were incomplete and did not guide staff on when to administer medicines, maximum doses, or how to review effectiveness. Outcomes were not always recorded. For one person prescribed a medicine to support them with distress and agitation, care plans and PRN protocols did not support staff with triggers or when to try non medicines approaches before giving the medicine. Incident records were not fully completed so staff and health care professionals could look for patterns and support the person in a positive way when they experienced distress.

Risks to people were not always assessed and managed in line with the providers polices. Staff were not following safe practice when supporting people to leave the service for short period of time with their medicines. Where people administered their own medicines, staff had not identified concerns we found during the inspection, placing people at risk of using expired medicines.

Medicines were not always stored safely. Fridge temperatures were recorded regularly, however maximum temperatures were repeatedly above the accepted range, over a long period. Staff had not recognised this or escalated it as per the providers policy. This meant there was a risk of people receiving medicines that were not suitable to use. Medicines being used for homely remedies [over the counter medicines which can be purchased by the provider for minor ailments] were not managed in line with guidance. Staff were using loose prescription only medicines and eye drops, which are for single use. There were no clear records of stock or administration.

We observed poor infection prevention and control practice during medicines administration, including inappropriate use of gloves and a lack of hand hygiene, which increased the risk of contamination. Used gloves and medicines packets were disposed of in a communal bin putting people at risk of cross contamination.

Monthly medicines audits had not been completed as per the providers policy. Where they had been completed, the concerns we found during the inspection had not been identified. Actions identified were not always supported by clear completion plans, and audit findings had not been addressed.

Following this inspection, the nominated individual acknowledged the concerns identified and confirmed they are taking action to address them. A nominated individual is the person appointed by an organisation to act on its behalf and ensure compliance with legal and regulatory requirements.