Chapter House Care Home

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• 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 69 (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 continually identify and embed good practice.

Systems and processes were in place to help keep people safe. Staff were knowledgeable about the policies and procedures for reporting accidents and incidents and followed them appropriately.

Records showed staff took prompt action when events occurred, including providing first aid, seeking medical support and making any necessary referrals.

The provider reviewed these records and carried out investigations to understand the causes, identify ways to prevent similar incidents and share learning with staff.

Relatives told us they were kept informed about any accidents or incidents involving their family members. One relative said, "They contact me if there are any changes with [person's name] They [staff] are very good at letting us know what is going on."

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.

The provider had a dedicated staff member in place who carried out the initial meetings with people prior to their move into the service. As part of this process, this staff member ensured all necessary assessments were completed accurately and in a timely manner to confirm the environment and support were appropriate for each person’s needs. They continued to meet with people and their relatives for up to 6 months. This ongoing involvement helped to promote a smooth transition, address any emerging concerns, and ensure the person remained happy and well supported during the early stages of their admission.

The provider 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. The provider shared concerns quickly and appropriately.

People told us they felt safe living at the service. Comments included, "I do feel safe here, the staff are very good" and "I like it here, I do feel safe." Relatives also confirmed that their loved ones were safe at the service. Comments included, "There is no question, the service is very safe" and "We know [person's name] is safe and looked after, we are happy it’s a good environment. [Person's name] has high standards and is very happy there."

The service had a safeguarding policy in place, and the management team followed both internal and external procedures to ensure people were protected. Staff demonstrated understanding of how to keep people safe and could confidently explain the action they would take to prevent harm or abuse.

We checked whether the service was working within the principles of the Mental capacity Act, whether appropriate legal authorisations were in place when needed to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met. All legal applications had been made in accordance with Deprivation of Liberty Safeguards (DoLS). This meant people’s rights were fully respected. The manager kept a record of DoLS applications and authorisations, and this was regularly reviewed to make sure authorisations were current.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Some care plans and risk assessments did not always contain detailed information about the risks to people and how these should be managed. Although risks relating to people’s individual health, safety and wellbeing needs was identified and recorded, some care plans and risk assessments were not consistent, and did not always provide clear, person-centred‑ guidance that reflected people’s individual preferences. For example, one person who was identified as being at risk of falls had experienced several falls in the past two months. The care plan did not clearly specify what type of footwear the person should be wearing to reduce this risk, which resulted in the person routinely using inappropriate footwear, and contributed to these repeated falls.

Health professionals confirmed staff followed their advice. However, they also reported concerns that the service did not always manage identified risks in the most appropriate or proactive way.

They said the service sometimes referred people to other agencies without first taking steps to mitigate the risks themselves, raising questions about the overall effectiveness of risk management.

Staff demonstrated a good understanding of specific risks relating to people's health conditions and where concerns were identified this was recorded and referred to appropriate health professionals.

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 service provided a welcoming environment with a pleasant atmosphere. Appropriate safety checks were carried out across all relevant areas and equipment, ensuring everything was functional and met required safety standards. Staff attended regular fire safety training and were able to describe the fire evacuation plan. There was a refurbishment plan in place for the kitchen and laundry areas.

The provider used a dependency assessment tool to calculate staffing levels within the service. However, people, their relatives, and some staff reported that they did not always feel there were sufficient staff available to meet people’s holistic needs.

The provider used a tool to plan staffing. However, rotas did not always reflect consistent staffing levels. On two floors, staffing appeared suitable, but on the floor where people required higher support needs, we saw delays in people receiving help.

People, relatives, and staff said staffing wasn’t always enough. One person told us they often waited longer than expected. Relatives also noticed reduced staffing at times, especially weekends, and a turnover of experienced staff. Agency staff were used to manage staffing shortfalls and were block‑booked to promote continuity of care and familiarity for people using the service. The provider understood the importance of a consistent staffing team and had already reduced reliance on agency staff, with further improvements being supported through ongoing recruitment.

New staff members received a thorough induction, which included training sessions and shadowing more experienced staff. Staff completed a range of training courses which included safeguarding, moving and handling, fire safety, health and safety and food hygiene.

Staff were recruited safely and appropriate checks were carried out to ensure they were suitable to work with vulnerable people. Staff received regular supervision meetings and competency was checked by senior staff.

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.

The service was maintained to a very high standard, presenting a clean, fresh, and inviting environment. Personal protective equipment was readily accessible throughout the service, and staff had good knowledge of effective infection prevention and waste management procedures.

The provider had an up ‑to ‑date infection control policy, and all staff had completed the necessary training.

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 received their medicines as prescribed. The service used an electronic recording system for the administration of medicines which contained all appropriate information to ensure the safe management of medicines. We identified one staff member had not followed the prescriber’s guidance for one person. This was immediately addressed by the manager.

Protocols for as and when required medicines were accessible to ensure people received medicines safely when needed. People’s preferences on how they wished to receive their medicines was clearly recorded. Risk assessments for people prescribed blood thinning medication were completed and informed staff of the potential complications associated with this type of medication.

Staff responsible for handling medication received training and the management team completed regular competencies checks to ensure correct practice was followed. Weekly audits were completed by the management team to address any shortfalls quickly and effectively.