Chelmsford Care Centre Ltd

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 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.

Leaders fostered a proactive and positive safety culture, underpinned by openness and honesty. Staff were encouraged to raise safety concerns, which were consistently investigated and reported. The service demonstrated a commitment to learning from incidents, using them as opportunities to identify and embed best practices.

Lessons learned from incidents was shared with the staffing team. Comments included, “We do a lessons learned or reflection practice. The manager sends the feedback which we read and then sign.” Another comment, “We now have meetings in relation to accidents and incidents, they [senior team] now update us, and when they discuss these, they let us know the cause so, we can avoid it happening again.”

The manager provided examples of how learning had been implemented following concerns or incidents. They explained, “I documented the lessons learned from our organisational safeguarding processes and shared them during staff meetings, flash meetings, and weekly clinical meetings. Maintaining staff engagement and transparency is essential to sustaining a culture of continuous learning.”

Leaders and staff worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Although the service had chosen not to accept any new admissions, they made sure there was continuity of care, including when people moved between different services.

At our last assessment we received concerns regarding the service accepting people from hospital through a discharge to assess (D2A) process without appropriate assessments being undertaken. The manager shared they had learnt from that experience and now understood the service had been accepting a high number of new admissions too quickly. The manager told us, “Our operations manager had a meeting with the D2A team, if we accept new admissions under this process moving forward, we will only accept 2 admissions a week and will carry out a face to face assessment to ensure we have accurate and updated information about the person’s care and support requirements.”

People and relatives told us they were kept informed and updated about any changes to their/relatives health and well-being. A relative told us, “They [staff] keep us informed on how [person] is doing and on their various conditions.”

We spoke with a visiting professional who told us, “I generally feel the home is ok, it is always clean, and the staff are responsive. As soon as I ask to see a person or need assistance from staff, they attend. ‘When I leave here, I don’t have any worries about residents.”

The service used agency staff on occasions. The agency staff we spoke with during our assessment stated they cared for the same person when they were on duty. This demonstrated continuity of care especially for those people who benefited from having the same staff.

Leaders and staff worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Leaders understood the importance of sharing concerns quickly and appropriately to the relevant authorities.

People and relatives, we spoke with raised no concerns regarding their or their loved one’s safety. Comments included, “We feel [person] is safe here and well looked after and you feel safe too”, and “I am unable to get out much now, so here they [staff] help me and keep me safe.”

Staff confirmed they had completed safeguarding training and demonstrated a clear understanding of how to prevent, identify, and report abuse. They expressed confidence that management and office staff would respond appropriately to any concerns raised, ensuring timely and effective action. A member of staff told us, “If I saw abuse, I would report to my unit manager or manager. Follow procedure, write a statement and complete an incident form. If I needed to report higher, I would report to the council or CQC.”

Leaders and staff worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Improvements identified during the previous inspection had been addressed, particularly with regards around risk monitoring for individuals. Staff were completing monitoring records more consistently, and people using the service, along with their relatives, did not express concerns around people’s risk management. Feedback included comments such as, “They’ve helped [person] regain weight, [person] has improved significantly since arriving”, “[Person] lost weight, so they’ve now been placed on a high-protein diet which started about a week ago and is already making a difference.” Another comment included “[Person] has plenty of fluids to drink each day. and we bring drinks in for [person] too. It is monitored anyway so we know exactly what [person] is drinking each day.”

Risks to people's health and wellbeing were assessed, reviewed regularly and recorded in their care plans. This included assessments for those at risk of malnutrition, dehydration or pressure injuries. Where necessary, referrals had been made to relevant professionals such as dietitians, speech and language therapists, and tissue viability teams for further evaluation and support.

Where people exhibited behaviours that could be distressing to themselves and others, there was improved guidance for staff to mitigate the risks to the person and others. We saw de-escalation techniques being routinely used prior to the use of psychotropic medication. Recordsprovided the necessary information demonstrating staff’s interventions and outcomes when a person became anxious or distressed.

A visiting professional told us, “The management has changed recently, and it seems better. ABC charts here are reasonable and we are not seeing an over reliance on psychotropic meds here.” (ABC charts are a tool used to analyse and understand behaviours by breaking down events into three key components: what happened before the behaviour (antecedent), the behaviour itself, and what happened immediately after (consequence). This structured approach helps identify triggers and patterns in behaviours, especially those that are challenging or problematic.)

Leaders and staff detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

People did not express any concerns about the environment. The premises were visibly clean, well maintained, and free from unpleasant odours. Staff were able to report maintenance issues, and the equipment observed, such as wheelchairs and moving and handling aids, were clean, in good condition, and fit for purpose.

Records showed that regular checks were carried out to ensure the safety of the premises, including gas, electrical, and fire safety inspections. Equipment was routinely checked, and personal emergency evacuation plans (PEEPs) were in place and regularly reviewed to reflect individuals’ support needs in the event of an emergency evacuation.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Robust systems were in place to ensure that staff were appropriately qualified, skilled, and experienced. Safe recruitment procedures were followed, with all necessary pre-employment checks completed, including Disclosure and Barring Service (DBS) checks and the collection of up-to-date references.

We observed that staffing levels were adequate, with a balanced mix of skills to meet the needs of individuals using the service. Staff confirmed that there were sufficient team members on duty to deliver safe and effective care. They also reported receiving a structured induction upon joining, along with ongoing training to support them in their roles. Nurses had undertaken training relevant to their professional duties and were supported in maintaining their Nursing and Midwifery Council (NMC) registration and revalidation.

The majority of people and relative feedback was positive in relation to staffing within the service. Comments included, “The weekends seem much the same staff wise but maybe a little quieter which I think is good for [person]”, and “There is always someone to help me, whatever I want I get.”

Throughout the assessment, we noted effective collaboration among staff from various departments, including kitchen, administration, and senior leadership, who worked together to support care staff, particularly during mealtimes.

During the assessment, we observed that infection prevention and control (IPC) measures were well embedded across the home. Designated IPC stations were positioned at key locations, including bathrooms and toilets, and were equipped with aprons and gloves in various sizes. Domestic staff were seen working throughout the day with appropriately stocked trolleys, including wet-floor signs that were used and removed as needed.

Staff demonstrated awareness of IPC protocols, including the correct use of colour-coded cleaning equipment and linen bags. The environment was clean, tidy, and free from odours. Hourly bathroom cleanliness checks were evidenced through visible time logs. Kitchen staff wore appropriate uniforms when delivering meals, and care staff wore clean uniforms and blue aprons during mealtimes. However, one kitchenette was found to be unclean, the microwave required cleaning, condiments had not been labelled, and boxes of breakfast cereals had been left open in a bottom cupboard and not stored in closed containers. The fridge freezer needed emptying, cleaning and defrosting and food items labelled. The sealant around the kitchen sink had come away and paint on the windowsill was found to be peeling and cracked. This was promptly addressed by management following our feedback, demonstrating a responsive approach to maintaining hygiene standards.

The service had recently been awarded a 5-star rating for the kitchen following a visit from an environmental officer.

No concerns were raised by people or their relatives in relation to infection prevention and control (IPC) at the service. The manager told us they carried out daily walk arounds and IPC audits were regularly undertaken. Staff had undertaken IPC training and policies and procedures were in place to support effective infection prevention and control at the service.

Leaders 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.

The nursing staff were responsible for administering medicines and we observed the safe management and administration of people’s medicines. Close attention was being paid to people’s time specific medicines, particularly for those who take Parkinson’s medicines which are required to be administered more frequently throughout a 24-hour period.

Medicines were stored correctly in a locked room. The medicine trolley was locked in between medication administration rounds and attached to the wall in the medicine room when not in use. Controlled Drugs were maintained safely, and the service had a protocol for their safe disposal. Samples of people’s medicines records and stocks were selected and checked, these reconciled which showed people received their medication as prescribed. We observed nursing staff gaining consent from people before administration and ensuring they took their medicines before signing the medicine administration record.

Medicine audits and checks were regularly completed and where shortfalls had been identified, actions had been taken to make improvements.