Chase Park Neuro Centre

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 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 Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People were at risk as medicines were not always safely managed, and risks were not always identified and managed.

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 did not always have a proactive and positive culture of safety based on openness and honesty.

The registered manager reviewed and fully investigated accidents and incidents, and actions were taken to prevent further occurrences. Individual incidents were recorded and reviewed to identify trends and themes. However, some issues relating to the safety of the home identified at the last assessment had not been used for learning and were still present at this assessment. For example, unclean shower equipment.

The registered manager completed lessons learned reviews to share with staff following our feedback. One staff member told us, “Lessons learnt are good as it identifies areas for improvement outlines specific steps to prevent reoccurring wrongs.”

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 moving to the home. This ensured the service could meet their individual care and support needs in a safe and dignified manner.

People were protected from harm and abuse. The provider followed internal and external processes to keep people safe.

The registered manager logged, fully investigated and notified safeguarding incidents to the CQC. Staff had received training around the Mental Capacity Act and safeguarding people from abuse and knew how to apply this.

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 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 registered manager kept a record of DoLS applications and authorisations, which were 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.

Staff did not consistently follow people’s care plans to mitigate risk. Although people had personalised risk assessments, including guidance for specific health conditions and emergency situations, staff did not always apply this information in practice. For example, people with diabetes had clear instructions for monitoring their blood sugar levels, yet staff did not always complete this monitoring, increasing the risk that people would not receive the correct intervention if their blood sugars were too high or too low.

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.

Doors leading to restricted areas were not locked and contained potential risks to people living at the service. This was discussed with the registered manager who took immediate action to address the concerns identified.

Some required actions from our previous assessment remained. For example, not all window restrictors were in place or correctly installed. During the assessment, the provider carried out a full review of all window restrictors and took any required action.

The provider completed a range of health and safety checks, including electrical, gas and water safety. Areas of the service had undergone refurbishment which provided a dementia friendly, positive environment for people living at the service.

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.

Some staff members expressed concerns that staffing levels were not always sufficient, while other staff expressed levels were adequate to meet people’s needs. Comments included, “Staffing levels for the majority of dayshift hours are suitable. Mornings can be very demanding specifically on the dementia unit” and “The rotas are planned well, and management ensures cover is arranged when needed. I’ve noticed that when it gets busy, colleagues step in to support each other so that people’s needs are still met without compromising safety.” Some staff expressed concerns, such as “Staffing levels I don’t feel are adequate, especially in the dementia unit,” while others felt staffing exceeded expectations, saying, “I find there are more than enough staff on shift which is good because everyone can give that bit extra for the people whether it be a chat, go to the park or sit and have a cuppa.”

The provider recruited staff safely and completed appropriate checks to ensure people were protected from harm.

The provider held regular staff meetings and staff received regular supervisions. People were supported by staff who had completed relevant training. This included person centred care, moving and handling, and safeguarding. Additional training related to specific health conditions, such as dementia and diabetes was included in the training staff were required to complete.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of possible infection spreading or share concerns with appropriate agencies promptly.

Although the provider had an infection and prevention control policy in place and all staff received appropriate training, staff did not always adhere to the required procedures. For example, equipment used to administer medicines was not cleaned between uses, and cleaning records were not always fully completed. Domestic staff were following the cleaning schedules; however, we observed shower chairs with visible staining and bathroom areas that required further cleaning. This was an issue previously identified at our last inspection. The provider advised that all areas are subject to routine cleaning and confirmed that replacement equipment had been ordered to address these concerns.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Medicines continued to not be managed safely at the home.

At the last assessment concerns were identified regarding the safe use of when required and variable dose medicines. These concerns remained evident at this assessment. Medicines labels, medicines administration records and guidance to support their safe use were contradictory, missing or incorrect. Reasons for, and outcomes of administration were not always recorded.

Staff did not always follow best practice standards. For example, some records showed National Institute for Health and Care Excellence (NICE) guidelines for the management of medicines were not followed. NICE guidelines are evidence-based recommendations for health and social care delivery within England and Wales.

A running stock balance system was in place. However, this was not consistently followed. For example, balances of ‘when required’ medicines were not often recorded. This provided no assurance people were receiving their medication safely and as prescribed. We found medicines in stock that were not on people’s records, or the strength in stock did not match the records. The ordering system at the home was ineffective as some medicines were out of stock. This meant people missed doses of prescribed medicines.

We found significant stocks of a thickening powder (used to reduce the risk of aspiration) in a unit of the service. We spoke with staff about how thickener was used and were not assured staff understood different people’s requirements. Guidance related to preparation of thickened fluids was unclear, so we were not confident the right thickness was being used for people.

The provider addressed some of the issues identified during the assessment and completed a lessons‑learned document relating to the safe management of medicines. Staff members had signed this to confirm they had read, understood and acknowledged its contents.

The home had a medicines review system in place; however, it had not identified the concerns we continued to see during this assessment.