Chatterwood 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 remained requires improvement. This meant some aspects of the service were not always safe. There was an increased risk people could be harmed.

The provider was in breach of legal regulations in relation to record keeping and notifying CQC about safeguarding allegations.

This service scored 62 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to identify and embed good practice.

Relatives said they were confident with the safety arrangements. A relative told us following an incident, staff had supported their loved one very well.

Staff told us they felt able to raise any safety related concerns and felt these were listened to. The nominated individual told us about learning which had taken place following a recent incident, which led to them strengthening people’s pre-admission assessments, to ensure the process was sufficiently effective.

The provider had policies and guidance for reporting safety events, including a falls management policy. Processes were in place to receive and act upon national safety alerts.

A person’s records showed, following their fall, the incident had been investigated to identify why they fell and if any further actions were required for their safety. A health care professional confirmed staff informed them if people fell and staff took any actions required.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

People’s needs were assessed prior to their admission, and we saw the most recent pre-admission assessment was detailed and personalised. Staff told us they were now required to complete a more detailed admission checklist, with set times for the completion of different tasks when people moved into the service.

There were processes to ensure information was communicated effectively between staff when people either moved into the service or returned from hospital. The provider ensured key information was shared with the heads of departments daily and then disseminated to staff during their shift handovers. A staff member confirmed, “New residents are discussed at the handover.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. However, CQC had not always been informed of all safeguarding events at the service.

The former registered manager had not notified CQC, as legally required, about 4 safeguarding alerts they had made to the local authority. CQC could not therefore consider if any regulatory actions were required for peoples’ safety. The provider acted when we brought this to their attention, to identify why they had been omitted and to strengthen their oversight.

However, people and their relative’s felt people were safe. Staff received relevant safeguarding training and understood how to escalate concerns. A staff member said, “Any concerns especially safeguarding, are reported to the management team and the safeguarding team if needed.”

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 identified where people had restrictions, which potentially deprived them of their liberty and complied with legal requirements. Staff had processes to track their progress including when those approved required renewal. People’s records clearly demonstrated the principles of the MCA had been followed and decisions had been made in people’s best interests.

We saw people were able to move through the service freely and their movements were not unnecessarily restricted. A person living with dementia was seen to be regularly moving throughout the service, with staff on hand to support them. This enabled them to exercise their rights, which staff balanced with their safety.

The provider continued to fail to always ensure all records relating to the management of identified risks to people were sufficiently effective to mitigate the risks of them experiencing harm.

Some care records relating to risk management still required improvement. Although people now had risk assessments for risks such as dehydration and constipation. The associated monitoring records did not always show people had been re-positioned as frequently as required within their care plan to mitigate the risks identified, or that they were offered the level of fluids as recommended. Monitoring records still did not always demonstrate people had been protected from unsafe care as some were incomplete.

We did not identify people had suffered harm as a result. However, poor record keeping increased the potential risk to people of suffering future harm. The provider was aware and was still addressing this issue.

People's records related to the management of their clinical risks lacked enough detail to ensure they received consistent and safe care. There was insufficient information and detailed guidance to instruct staff in relation in the safe use of devices, such as catheters or those used for suction or blood sugar monitoring. The lack of sufficient written guidance put people at potential risk of unsafe care.

People had the equipment they required to manage identified risks, but people's air mattresses were not always set correctly according to their weight, which meant they may not be effective.

However, staff had completed relevant training in relation to the management of risks to people and had access to the provider’s policies to guide them.

We saw examples of where staff had consulted people, including those living with dementia about how they wanted their risks to be managed. This involved staff explaining the risk to the person in a way they could understand and agreeing with the person measures to mitigate the risk.

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

The premises were well maintained and safe, we saw safety equipment such as window restrictors were in place throughout. The provider ensured required safety checks had been completed as required in relation to fire, gas, electrical, water and equipment safety.

Staff told us there were processes to report concerns which were acted upon promptly. Staff had completed relevant training for example, in relation to fire safety and the safe use of bed rails.

There was appropriate signage to orientate people around the building. The building was secure to ensure people’s safety.

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.

Staff were recruited safely and required pre-employment checks had been completed. The provider ensured staff provided a full employment history and there was evidence of their conduct in previous roles. Staff received an induction which was tailored to their role. Staff completed a range of role specific training, including appropriate training for people with a learning disability and autistic people. Staff had competency assessments, for example, nurse’s clinical skills were assessed.

Staff had not received supervision as regularly as required by the provider's supervision policy during 2025. However, the provider was aware of this issue and had taken action to address this prior to the inspection. Staff spoken with felt supported in their work.

The provider used a staffing dependency tool to determine the numbers staff required on each shift. There was a mixture of nurses, nursing assistants and care staff rostered. People and relatives said there were enough staff to support them. We always observed, including during busy periods such as lunchtime, there were sufficient staff deployed.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

We observed the service was clean and fresh throughout. Staff were observed to wear appropriate personal protective equipment (PPE) and removed and disposed of it correctly. People did not raise any concerns about the cleanliness of the service.

Staff had completed the provider’s infection prevention and control training. Staff had no concerns about either their training or the infection control processes within the home.

The provider’s infection prevention and control processes reflected good practice guidance. The provider had an infection control champion and staff followed the cleaning schedules for the home. Processes were in place to audit the effectiveness of the infection prevention and control processes, staff training, and rates of infections within the home.

Staff ensured required food safety checks were completed and the home had a food hygiene rating of 5 which meant the standards were very good.

The service made sure medicines and treatments were safe and met people’s needs, capacities, and preferences by enabling them to be involved in planning, including when changes happen. However, improvements were needed for medicine storage.

There was an adequate stock of prescribed medicines. Medicines, including controlled drugs, were stored securely. However, staff did not monitor the fridge temperatures daily. Where medicines fridge temperatures were recorded, they were regularly not within the required range of between 2 and 8 degrees Celsius. Medicines not stored at the manufacturers recommended temperatures can lose effectiveness which may put people at the risk of harm.

Our observations and records showed people were having their medicines administered as prescribed. Records we reviewed showed medicines were not used to control people’s behaviour.

Person-centred care plans were in place to support people with their medicines. Some people were prescribed medicines to be administered on a when-required basis for health conditions such as constipation, pain, and anxiety. There was guidance in care plans and protocols for these medicines to be administered consistently.

Staff carried out appropriate assessments when medicines were administered covertly. Covert administration of medicine is when it is given in a disguised form within food or drink without the knowledge or consent of the person. However, for 1 person who had mental capacity and was being administered medicines mixed with food to help them swallow it. We found advice was not sought from the pharmacist on whether the medicines could be mixed with food and drink to administer them safely.

There was a medicine policy. Staff received training and were competency assessed to manage medicines safely. There was a process to report and investigate medicine incidents. The staff carried out monthly medicines management audits. However, the audits did not identify the gaps we found during the inspection related to medicine storage.