Archived: The Chantry

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. The inherited rating under the previous provider was good. This key question has been rated 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 service was in breach of legal regulations in relation to safe care and treatment, equipment, and premises. The provider had not ensured there were effective systems to safely manage people's medicines. The provider did not have effective systems in place to ensure the premises where care and treatment were delivered were always clean, suitable for the intended purpose and well maintained.

This service scored 56 (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 reported safety events. Staff knew where to record incidents and accidents and told us they had discussed learning when things went wrong. However, staff were not always able to provide specific examples of what they had learnt or what changes had been made as a result. Processes needed to be improved to ensure lessons were learnt to continually identify and embed good practice. Staff meetings were recorded, team huddles were undertaken twice daily, the provider held an accident/incident overview and although it identified any themes/trends for lessons learned, it was not clear as to how this information was shared with staff in a more formal capacity.

The provider had processes to monitor safe systems, pathways and transitions. This included a needs assessment. 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 in or out of the service with particular emphasis on those people admitted for periods of rehabilitation care and treatment. We observed professional discussion during a team huddle relating to carrying out an assessment of a person in hospital to ensure their safe admission back to The Chantry.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and reported safety events. Staff knew where to record incidents and accidents and told us they had discussed learning when things went wrong. However, staff were not always able to provide specific examples of what they had learnt or what changes had been made as a result. Processes needed to be improved to ensure lessons were learnt to continually identify and embed good practice. Staff meetings were recorded, team huddles were undertaken twice daily, the provider held an accident/incident overview and although it identified any themes/trends for lessons learned, it was not clear as to how this information was shared with staff in a more formal capacity.

People’s care plans included assessments which identified their potential risks and measures for staff to minimise them. However, we found people did not always receive care in accordance with the risk assessments outlined in their care plans and not all risks were correctly recorded. For example, we identified gaps in records we reviewed relating to people’s daily food/fluid/PEG/Gastroscopy feed regimes. For 1 person who required their food and fluid intake to be recorded daily and for staff to monitor their weight weekly due to weight loss, the registered manager was unable to provide us with the recommended daily fluid target amount set for this person as guidance for staff. Having a set daily fluid target is important, adequate hydration is crucial for maintaining overall health, supporting bodily functions and prevent dehydration – related issue like constipation, kidney stones and urinary tract infections. Weekly weights were not being undertaken for this person, monthly weights were being recorded and action taken was to continue on food/fluid chart and encourage diet and fluids. Although staff demonstrated they were aware of potential risks in people's daily lives and explained people’s current needs and how they wished to be supported, the provider was unable to demonstrate staff were consistently supporting people in line with the guidance in their risk assessments.

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 identified a lack of storage facilities on the first and second floor. Upon entering a person’s bedroom, we saw to the far end of their room a hospital bed and other equipment stored on the floor. People’s bedrooms being used to store equipment is neither dignified nor respectful of the person’s personal space. The registered manager told us they were looking into dividing the bedroom to enable a storage pod to be put in place as they were unable to transport the beds around the service as they would not fit into the lift.

On the second floor we found a shower room full of equipment such as hoists and commodes. This had been identified in the monthly environment audit undertaken on the 12 March 2025 where it stated ‘staff asked to remove’ however on day 2 of our visit on the 27 March 2025 it had not been cleared.

Observations throughout both days, identified staff struggling to assist people back to their bedrooms on the first and second floors into the small lift spaces. One manoeuvre we observed required 2 members of staff to carry out several manoeuvres of a person’s specialised chair to align the wheels correctly. This took several minutes to be able to fit into the lift space, having to go in backwards ending up with their back against the lift wall leaving no room to move safely or comfortably.

The premises/environment was in need of repair and upgrade to ensure spaces were suitable and comfortable. Many areas although clean, were tired and showed signs of wear and tear. The provider had a service development plan in place which had identified many areas needing improvement or upgrading. Some of these works were already underway, however the providers we were not assured timescales stated 2025, ongoing or ASAP through most of service development plan and did not provide a realistic, clear and robust prioritisation of scheduled works.

People and their relatives/representatives gave us mixed feedback when asked if there were enough staff available to provide care and support to people. Comments included, "I am very confident with the care [person] receives. They (staff) understand them and are always gentle and careful with them, like moving [person] in pairs to and from their wheelchair”, “At times there are loads of staff, then at other times, it’s more difficult to find a carer.” And “Some days there are not enough staff on duty, especially at weekends.”

Staff told us they felt there were enough staff available to keep people safe; however, some expressed concerns regarding the high volume of agency staff covering shifts at The Chantry. Comments included, “Depends on the day, we do have regular agency staff who have been orientated to our way of working. Yesterday there was a lot of agency staff, but I know there are more coming on board”, “We have enough staff to meet people’s needs. We have a number of agencies we can call if we are short staff.” And “We are usually staffed well during the day and night.” We observed appropriate staffing levels in the service during both days of our assessment. Staff were visible and available to provide people with support when needed.

We reviewed rotas over a 4-week period and could see new staff being onboarded. The registered manager was confident the levels of agency use was gradually reducing and told us once new starters had completed their onboarding and induction period; they would be able to see a significant reduction in their agency hours.

Systems were in place to ensure there were suitably qualified, skilled and experienced staff and safe recruitment practices were followed. We checked the recruitment records for 3 members of staff and all the required pre-employment checks had been completed. This included disclosure and barring service (DBS) checks and obtaining up to date references.

The service requested wherever possible regular agency staff for continuity of care. However further improvements were required relating to the oversight of agency staff profiles. We found of the 8 profiles we reviewed 7 were headed ‘The Disabilities Trust Agency Staff Profile’ and it clearly stipulated ‘No e-learning courses are permitted. All staff must have Moving Handling Training – Practical and Theory. Staff must have completed relevant face to face training - same day courses / induction courses are not permitted.’ However, for example we found 4 out of the 8 had completed most of their mandatory training subjects in 1 day. One staff member had completed 13 training courses in 1 day. We found no evidence to suggest this had been identified and what action if any had been taken.

People were not always protected from risk of infection. On day 1 of our assessment, we found out of date and unlabelled food items in the main dining room fridge. Containers to house breakfast cereals were labelled dating back to January and February 2025 so we were unable to determine how often breakfast cereals were being replenished. A large sideboard had a glass/Perspex top which was cracked all the way through allowing food debris to accumulate. The registered manager responded immediately to our concerns. On day 2 of our assessment, we found all food items in date, labelled and the glass/Perspex top had been removed.

We found in 1 communal bathroom the toilet roll holder on the floor as it had been attempted to be held in place with double sided adhesive strips. Poor/unfinished paint work and paperwork dating back to September 2024 left in the bathroom. One person’s pressure relieving mattress the top layer had worn completely on both sides and the arms of another person’s recliner chair was noted to be torn.

The provider completed regular infection prevention and control audits. However, we identified several infection control risks which had not been addressed at the time of the assessment and the providers infection prevention and control policy we requested had expired.

The provider did not always ensure that medicines and treatments were safe and met people’s needs, capacities and preferences. On the first day of our visit, we undertook a count of some people’s medicines to check they matched with the service’s electronic system. We found it difficult to reconcile people’s medicines as what was showing as the balance on the electronic system was not accurate on the physical count of some people’s medicines. We found the same issues on the second visit a week later despite the head of care undertaking a full audit across the service. We could not be assured people always received their medicines safely and as prescribed. We could not be assured staff were always following prescribers' instructions when administering medicines. For example, for 1 person who had been prescribed a topical cream to be applied 3 times a day, records identified staff were only signing for the morning application so we could not be assured this medication was effectively treating the condition it was prescribed for. The provider did not have a robust auditing system as it had failed to identify gaps in people’s PEG/Gastroscopy feed charts as well as other medicine issues identified during the assessment process.