Christopher Grange Residential Care

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 people were protected from abuse and avoidable harm.

This is the first assessment under the provider. This key question has been rated inadequate. This meant people were not safe and were at risk of avoidable harm.

The provider was in breach of legal regulation in relation to people’s safe care and treatment.

This service scored 25 (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 did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice. For example, the systems meant to keep people safe and prevent avoidable harm were not effective. In the last 4 months there had been 30 falls recorded across all three units. Despite this, there was no evidence of robust investigation, analysis, lessons learnt or action to reduce the likelihood of recurrence. Following a recent safeguarding investigation undertaken by the local authority the provider and registered manager had failed to implemented actions to mitigate further risk of harm to people.

The provider did not work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. For example, the initial assessment of need completed by the registered manager for a person prior to their admission to the home failed to capture essential information about their safety and wellbeing. This led to the person having to be discharged back to their previous home on the same day of admission causing them anxiety and distress. Hospital transfer records for another person did not provide essential information about their medical history and personal care needs to ensure they received safe and effective care during their stay in hospital.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately. For example, safeguarding records reviewed showed a number of incidents and injuries resulted in hospital admissions but had not been reported through the providers safeguarding procedures. Training records showed 50% of care staff and 60% of senior care staff had not completed up‑to‑date safeguarding training. This limited staff’s ability to recognise, report, or appropriately respond to potential safeguarding concerns.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. For example, known risks to people were not consistently monitored in line with their risk management plans placing them at risk of harm. Monitoring records for one person at risk of malnutrition and skin breakdown showed they had not had their weight monitored each week nor had they been repositioned at the required intervals. Risk assessments had not been completed for another person diagnosed with epilepsy and diabetes.

The provider did not detect and control potential risks in the care environment. They did not make sure equipment, facilities and technology supported the delivery of safe care. For example, unsecure doors, broken furniture and hazardous flooring. In addition, radiator covers were in disrepair providing people with direct access to hot radiators. Doors were left open to rooms under refurbishment which contained hazardous items, and a communal bathroom was being used as a storage area, rendering it unsafe. Bathing facilities were inadequate due to broken fixtures, low water pressure or rooms filled with stored equipment; across all units there was only one fully functioning shower, the bath on one unit was broken, and the baths on the other two units were not in use because they were used for storage. Trailing wires were observed in bedrooms.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support and development. They did not work together well to provide safe care that met people’s individual needs. For example, we observed a significant delay in people receiving personal care due to the lack of staff availability. Staff told us they did not have sufficient time to provide care in line with people’s assessed needs and care plans. One staff member told us, “Due to current staffing levels service users are being neglected and only receiving one shower a week or even a fortnight.” This reflected our wider findings. The call bell log showed multiple examples of extended periods of unanswered calls leaving people waiting for assistance. Overall, staffing numbers, skill mix and deployment across units did not reflect people’s dependency levels, needs or the environment. Training records showed a high number of staff had not completed mandatory training set out by the provider. This increased the risk of people receiving unsafe care.

However, safe recruitment processes were followed.

The provider did not assess or manage the risk of infection. They did not always detect and control the risk of it spreading. For example, we found issues with cleanliness and infection control across all units. Mobility equipment such as stand aids, wheelchairs and walking aids was visibly dirty and not always cleaned between uses. Shower heads and shower chairs needed cleaning, and communal toilets were unclean. In several areas the environment was tired and was hard to keep clean, with heavily stained carpets and damaged skirting, walls and floor edges.

The provider did not make sure medicines and treatments were safe and met people’s needs, capacities and preferences. For example, we found medication administration records (MARs) across all three units did not evidence prescribed creams and ointments were applied to people’s skin as directed. Prescribed creams were observed in people’s bedrooms, and some had prescription labels that were illegible. A prescribed thickener was stored insecurely in a satellite kitchen that was accessible to people. Time‑specific medicines were not consistently administered as prescribed, so people did not always receive the correct dose at the correct time. In addition, clear guidance for staff on the indications, timing and maximum doses for ‘as required’ medicines were not consistently available.