Chestnut Court Care 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 good. At this assessment the rating has remained 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.

The provider had systems in place that meant that practice could be reviewed, and lessons learnt to continually identify and embed good practice. People and their relatives knew how to raise concerns and felt confident that they would be addressed.

The provider had systems in place to regularly review all aspects of practice and identify gaps in learning. Regular visits to the service by senior managers and those dedicated in carrying out quality control checks helped the service identify areas that could be improved upon.

Staff told us about the openness of the management and the ease they felt they had in sharing their thoughts and ideas which ensured the service continued to learn.

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 systems in place which helped provide a smooth transition between care settings. For example, pre-admission assessments were carried out with people and their relatives before they moved into the service. This helped the service understand the support required to meet people’s needs.

The service assessed people in their own homes and those who were in hospital. They were able to gather the information required to be able to develop a care plan that allowed them to respond to people’s care needs in a timely way.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that.

Staff told us they had undertaken training about safeguarding adults. They were knowledgeable about the different types of abuse that might be found in a care home and were aware of their responsibility to report any allegations of abuse. One member of staff told us, “I would go to [line manager] and then [registered manager] if I thought there was abuse.”

The manager worked closely with local authorities and kept clear records about safeguarding events that happened within the service and ensured that information was shared with other professional bodies when required.

The provider did not always work well with people to understand and manage risks. For example, one person was assessed as having an increased risk of circulatory and respiratory complications. One of the actions in the care plan to address this risk was to check the person’s blood pressure. However, the plan did not say how often this should be done, merely that it should be done ‘regularly’, which was very imprecise. Records showed the person’s blood pressure had not been checked since 3 July 2025, more than 6 weeks before the date of our inspection. We discussed this with a nurse on duty who arranged for the person’s blood pressure to be checked the same day. However, the lack of a proper system for checking the person’s blood pressure placed them at risk.

We saw a range of risk assessments for people which was dependent upon the support people needed. We saw other assessments around people falling, requiring support to eat as well as nutrition and hydration. We also saw risk assessments for people who needed one to one support throughout the day. Most risk assessments we saw were detailed and had highlighted what staff needed to do to keep people safe.

Systems were in place to help ensure the premises and equipment used were safe. The provider carried out some of their own safety checks, for example, on fire alarms and emergency lighting. Qualified people were employed to carry out safety checks including on the gas, electrics and fire alarms in the home. We toured the premises and found the environment to be safe, although one of the lifts was not working at the time of inspection. The registered manager told us they hoped this would be repaired within the following 2 weeks and as there was a lift in good working order so there was limited impact upon the service.

We observed that there were enough staff to meet people’s needs. For example, when call bells were sounded, people did not have to wait long for a member of staff to attend to them. Staff we spoke with told us there were enough staff to meet people’s needs. However, one member of staff said sometimes they were so busy they were unable to take their scheduled breaks. We discussed this with the registered manager who said they would look into the matter.

The provider carried out checks on prospective staff to help ensure they were suitable to work in a care setting. These included employment references, proof of identification and of the right to work in the UK and criminal records checks. We were told that the service did not use any agency staff. When staff cover was needed, the provider had a pool of bank staff to use.

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 provider had a policy detailing the risks and preventative strategies they had in dealing with risks of infection and the spread of diseases. Staff received training on how to protect people they supported and themselves. Throughout the inspection we observed staff wearing personal protective equipment. The premises were visibly clean and free from odours.

The provider made sure that medicines were safe and met people’s needs. The provider held weekly reviews with a GP who visited the service every week where concerns relating to people’s medicines could be discussed. The GP told us that they routinely reviewed every person’s medication every 3 months as well as annually.

Systems and practices the provider had in place were robust, ensuring that all medicines were stored and administered in a way that met all aspects of the quality standards and good practice guidance of the national institute for health and care excellence.