Charnwood House

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. This is the first assessment for this newly registered service. This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Charnwood House promoted a strong and positive learning culture. Leaders and staff placed clear value on reflection, improvement and continual learning, and this was evident in the way the team approached risk, challenges and change.

The service had effective systems in place to identify trends and patterns across incidents, daily records and safeguarding concerns. Staff understood why learning from these trends was important and could explain how this information helped them improve practice and prevent issues from recurring. This demonstrated that learning was embedded rather than reactive.

Positive risk‑taking was encouraged and supported. Staff told me people were not restricted unnecessarily and that risk was approached in a balanced and person‑centred way. Where things did not go to plan, setbacks were not viewed as failures. Instead, they were treated as opportunities to gain further insight into what worked well and what needed to be adapted. This approach helped staff feel confident in promoting independence while maintaining safety.

The service had effective mechanisms for sharing lessons learned. Staff received feedback through team meetings, reflective discussions, formal supervision and ongoing mentoring provided by the registered manager. This ensured learning was communicated consistently and that staff had the opportunity to discuss how it applied to their day‑to‑day work. Staff reported that they felt supported, valued and encouraged to develop their skills.

The registered manager worked safely and effectively with people and healthcare partners to establish and maintain safe systems of care. Safety was monitored well, and systems were in place to ensure that people experienced continuity of care, including when moving between different services.

The provider had clear processes to assess and plan for people’s needs before admission. For example, they used an ‘enablement panel’ meeting for individuals who required additional support with managing specific health conditions. This process enabled the registered manager to consult with senior managers who had specialist knowledge, ensuring that the service fully understood the person’s needs and could meet them safely before any transition took place. This helped prevent avoidable or inappropriate admissions and promoted smooth, well‑managed moves into the service.

People also had important documents in place, such as hospital passports. These included personalised information about how individuals wished to be supported, their health needs and their preferred communication methods. This meant that if people needed to access other services, professionals had essential information immediately available. It helped people communicate their story without having to repeat information and reduced the risk of inconsistent or unsafe care during transitions.

Staff had a good understanding of people’s personalised risks and safeguarding needs. Staff were able to clearly describe the specific vulnerabilities of each person they supported, including risks related to communication, health conditions, behaviour, and social situations. This demonstrated that they knew people well and were confident in recognising even subtle changes that might indicate increased risk.

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. The Registered Manager demonstrated strong oversight of safeguarding and worked within the principles of the MCA. We found that issues were identified quickly and, staff followed the organisation’s procedures correctly and informed the registered manager without delay. They assessed concerns promptly, took proportionate action based on level of risk, and made timely referrals to the relevant external agencies, including the local authority safeguarding team, health professionals, and the Care Quality Commission. Lessons learned were shared with staff, which strengthened the service’s safeguarding culture.

Staff involved people when understanding and managing risks associated with their care and daily lives. The provider used recognised tools, including Baseline Risk Assessments, to identify potential hazards and establish a clear starting point for safety planning. These assessments considered a wide range of factors, such as environmental risks, health‑related concerns, behavioural triggers and safeguarding issues, ensuring staff had a comprehensive understanding of each person’s needs.

Staff used this information to work collaboratively with people, helping them understand identified risks and agree on practical strategies to keep themselves and others safe. People were encouraged to express their views, preferences and concerns, and staff supported them to make informed decisions about how risks should be managed.

We saw that staff applied risk management plans consistently and reviewed them regularly with people. This included discussing any changes in behaviour, health or circumstances and updating plans to reflect new information.

The registered manager had created a safe and responsive environment that effectively supported both people and staff. Safety measures were carefully considered and proportionate, ensuring that people were protected without unnecessary restrictions being placed on them or their surroundings.

Staff had access to emergency alarms, which they could activate if they required immediate assistance. This system was used particularly when people experienced periods of frustration or distress that could escalate into behaviours involving physical aggression. The alarm system ensured staff could access prompt support, reducing the need for restrictive practices and helping to maintain a calm and controlled environment.

I observed that this approach promoted safety while respecting people’s independence. Rather than placing constant staffing restrictions on individuals or limiting their movement, the service used the alarm system as a contingency. This enabled staff to work confidently with people on a one‑to‑one basis, knowing additional help was readily available if needed.

Records showed that the use of this system had contributed to positive outcomes. People who had previously required continuous support from two staff members were now able to be supported safely by one staff member, thanks to the availability of timely backup. This reduced unnecessary restriction, increased autonomy for people, and supported the development of trusting relationships between individuals and staff.

The provider had safe and effective staffing arrangements in place. Safe recruitment practices were followed consistently, including carrying out background checks, verifying employment histories and obtaining appropriate references before staff began working at the service. This helped ensure only suitable and trustworthy individuals were employed to support people.

The provider made sure there were enough qualified, skilled and experienced staff on duty to meet people’s needs safely. Staff told us they felt confident in their roles and had access to regular supervision, support and development opportunities. Training records showed staff received the learning they needed to carry out their responsibilities effectively, and new staff were supported through a structured induction.

We observed staff working well together as a team, communicating clearly and sharing information to ensure people received consistent, safe care. One staff member said, “Staffing levels are good, we always get enough time to spend with people to meet their care needs as well as their social needs. The registered manager always helps out if needed.”

The registered manager had effective systems in place to assess, monitor and manage the risk of infection. They demonstrated a clear understanding of current infection prevention and control (IPC) guidance and had measures in place to prevent infections from spreading throughout the service. Risks were reviewed regularly, and the manager acted promptly when concerns were identified, ensuring that appropriate agencies were informed without delay.

Staff understood their responsibilities and followed safe practices such as good hand hygiene, correct use of personal protective equipment (PPE), and appropriate cleaning routines. Records showed that infections were monitored closely, and any patterns or emerging risks were escalated for further investigation. This ensured that action could be taken early to minimise the likelihood of outbreaks.

Charnwood House had successfully integrated IPC measures without compromising the homely environment. For example, cleaning products and PPE were stored discreetly but remained accessible to staff when needed. Communal areas were kept clean and hygienic, yet still warm, personalised and comfortable. People’s bedrooms retained their individuality whilst maintaining high cleanliness standards.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. People were given their medicines safely and in a timely manner. This was recorded on their medicines administration record (MAR) and medicines were stored safely and securely. There were processes in place to ensure the safe and effective use of medicines.

Detailed guidance specific to each person on how to administer medicines prescribed as and when people required them, known as “PRN” was available to staff. However, the dose on 1 residents MAR chart was different to that shown on the PRN protocol and the pharmacy label attached to the dispensed medicine, which could result in the wrong dose being given. The registered manager acted immediately to the feedback and ensure appropriate change were made to records and staff were notified.

Some medicines were prescribed with a variable dose, for example, 1 or 2 tablets to be given when required at regular intervals. The quantity given had been recorded, meaning records accurately reflected the treatment people had received. The service had individual fire risk assessments in place for people who were prescribed paraffin-based skin products. The use of topical creams and ointments were recorded on the medicines administration records (MARs). Body maps were in place to show staff the site of application. We checked the quantities and stock balances for each resident and found them all to be correct.

People were seen by their GP at least annually for a routine check-up in line with national guidance. Hospital Passports were in place for each resident which ensured that information about a resident’s medicine went with them upon admission to another healthcare setting. There was evidence that there was a process in place to record medicines related incidents or errors. Records showed that staff had received medicines handling training. Staff competencies were assessed regularly to make sure they had the necessary skills. Managers and members of staff qualified to handle medicines regularly completed audits (checks) to make sure that procedures were followed.