Chorlton Place Nursing 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 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 regulation in relation to safe care and treatment. Medicines were not always safely managed and risks to people’s health and safety were not thoroughly assessed to keep people safe.

This service scored 50 (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 consistently foster a culture of safety. Improvements were necessary to enhance oversight and promote continuous learning and improvement in the monitoring of safety-related events. However, gaps remained in identifying preventative measures for certain situations, such as when an individual becomes acutely unwell.

Staff reported that learning from safety incidents was shared through team meetings, individual and group supervision sessions, and daily flash meetings. There was a clear understanding among staff of their duty to report accidents and incidents. These events were reviewed by the wider management team to identify patterns and implement risk-reduction strategies, such as the use of fall-monitoring equipment. One staff member told us, “We record incidents on the online system and ensure all relevant information is shared with managers. We also carry out and document full body checks to monitor skin integrity.” Following some incident’s, a root cause analysis was conducted, which included reflective practice for staff.

The provider did not always establish safe systems of care. Working arrangements were in place with system partners to support safe and effective hospital discharge processes. However, it was noted that not all individuals were afforded the opportunity to choose their preferred place of residence upon leaving hospital. One relative reported that their family member had not been offered a choice by the hospital discharge team, which had adversely impacted their well-being and potentially placed them at risk.

To facilitate timely discharges and ensure care suitability, the provider employed trusted assessors who carried out assessments of people’s' needs. However, we found assessments contained gaps in pertinent information. The provider worked closely with community healthcare professionals, including general practitioners and district nurses, to reduce avoidable hospital admissions and ensure people could remain at the home, cared for by staff familiar with their requirements.

Safeguarding procedures were established, and staff demonstrated awareness of appropriate reporting channels for any concerns. All staff had received safeguarding training, which contributed to their confidence in escalating issues either internally to management or externally to relevant health and social care professionals. The provider responded to concerns in an appropriate manner, and outcomes from safeguarding incidents were reviewed, with learning shared across the staff team.

People living at the home, reported feeling safe within the home and confirmed that they were treated respectfully by staff. One person stated, “If I am worried, I can tell the staff.” Feedback from relatives was varied; while some expressed no safeguarding concerns, others indicated they had previously raised issues through formal channels. These formal concerns were found to have been appropriately addressed.

Further improvements were required to ensure staff fully understood the risks associated with individuals’ care and support. Some epilepsy care plans lacked accurate post-seizure guidance. One care plan incorrectly recorded a requirement for rescue medication that had not been prescribed. This error was corrected following our visit.

The management of oxygen therapy was not safe. One person’s oxygen needs had not been sufficiently risk assessed, and the associated care plan lacked clear guidance for staff. Observations indicated that health and safety protocols regarding oxygen use were not consistently adhered to, presenting a potential risk. It was unclear whether the nasal cannula was routinely changed, and no action had been taken to prevent it from being left on the floor. This posed infection control concerns as well as a trip hazard and potential obstruction to oxygen flow. Additionally, the provider had not considered environmental contaminants that could compromise the cannula’s safety, and we found equipment was not consistently cleaned according to the manufacturer’s instructions.

think it should say, ‘One person had a pacemaker implanted which was not captured in the person’s care plan and risk assessment. There was no additional information as to how the pacemaker should be monitored or the risks it presented to the individual.

Several diabetic care plans were found to be insufficiently detailed. The provider had identified this as an area for development. Despite this, staff demonstrated awareness of people’s risks and were able to explain how these would be mitigated.

Risk management practices relating to falls, choking, weight loss, and skin integrity were generally well managed. Care records reflected identified risks and were regularly reviewed to ensure they remained effective. Fall risk assessments appropriately balanced safety and independence; for example, people with a high fall risk who were mobile were provided with sensors to monitor when they were mobile.

Staff could identify those people at risk of developing pressure ulcers and described preventative measures implemented to support skin integrity. In relation to swallowing difficulties, staff were confident in their knowledge and training. One staff member stated, “I have had International Dysphagia Diet Standardisation Initiative (IDDSI) training and it’s in all the care plans to follow.” Another added, “I administer thickeners. I’ve had all my training. I’m very confident in this. I know who has thickeners and where to find the information on this.”

The provider employed a maintenance team responsible for overseeing both internal and external upkeep of the premises. Regular internal checks were undertaken to assess the safety of critical systems, including fire protection measures, moving and handling equipment, food catering safety, emergency lighting, and nurse call systems.

External servicing of essential equipment such as gas and electrical systems, passenger lifts, moving and handling equipment and firefighting equipment was carried out in accordance with the respective manufacturers’ guidelines. Internal safety monitoring was supported by maintenance logs detailing daily, weekly, and monthly assessments. Any required remedial actions were clearly documented and promptly resolved.

Our observations found, there were sufficient staff on duty during our assessment. All staff received supervision, development opportunities and ongoing training. However, some staff did share they would prefer more face-to-face training rather than e-learning. We found not all staff had been provided with training in the use of oxygen therapy, despite people at the home using oxygen therapy.

Staffing levels were informed by a dependency calculator that took into account the individual needs of people living at the home. Reviews of staff rotas confirmed a consistent and stable workforce across the home. However, feedback from staff regarding staffing levels was mixed. Some noted that the increased complexity of residents' needs such as a rise in manual handling requirements, was not always reflected in staffing allocations. One staff member commented, “There is lots of hoisting on this floor now. There never used to be any, and the people’s needs are higher, but there’s no more staff. The numbers include the seniors, so it doesn’t leave many carers to do the work.” Other staff reported that current staffing levels were appropriate to meet residents' needs.

Recruitment processes were robust, with new staff receiving comprehensive induction and training prior to undertaking care responsibilities. Observations indicated that staff were not rushed and responded to people’s needs in a timely manner. One resident shared that staff routinely engaged with them through conversation.

Agency staff were used occasionally to fill for annual leave and staff absence. Agency staff received an induction to the service.

One relative told us, “The staff work really, really hard to make sure that [Name] is clean. [Name] gets fed all day long, literally all day long, and has drinks all the time. When [Name] calls the bell, they bring her a cup of tea. It’s great!”

Infection control was generally well-managed. Housekeeping staff were deployed daily to maintain both routine and deep cleaning schedules. Cleaning records confirmed that high-touch and frequently used surfaces were regularly sanitised.

While the home was observed to be clean and well-maintained during our visit, feedback from some relatives was mixed. Concerns were raised regarding the cleanliness of certain bedrooms, including reports of unclean en-suite facilities. Two relatives told us there had been an ongoing issue with mice in the home. We saw pest control services were regularly attending the home and further actions had been taken, including providing additional staff training to try and mitigate the issue. We were provided with photographs from one person’s bedroom which identified evidence of mice. The provider was confident the issue was under control.

A third relative told us, “The place never smells. They’re constantly cleaning, all the communal areas, all the rooms, and my mum’s bedroom. It’s always cleaned.”

Staff showed a clear understanding of infection control procedures, including the correct use and disposal of personal protective equipment (PPE) such as gloves and aprons. We observed staff adhering to hand hygiene protocols and encouraging residents to wash their hands before and after meals.

Food safety and hygiene were actively monitored. The kitchen had achieved a 5-star food hygiene rating, reflecting high standards in food preparation and cleanliness.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

Some improvements had been made in the safe management of medicines since the last assessment, however, there were still some aspects of medicines management that were unsafe.

Nine people missed doses of some of their prescribed medicines for varying amounts of time. Some people missed one dose of their medicine, but one person missed having their mood stabiliser for 5 days because medicines were not available in the home.

The electronic medicines records were not always accurate, and this led to two people being given the wrong doses of their medicines and one person’s cream was not applied for a week.

Insulin was not always managed safely. One person was not given their prescribed dose of insulin on 7 occasions and another person did not have their blood sugars levels monitored safely on 13 occasions. Their insulin was not stored at safe temperatures for over a month.

When people were prescribed medicines to be taken with a choice of dose, the protocols to support their administration were not detailed enough to ensure they were administered safely and consistently.

Waste medicines were not stored safely in line with current guidelines.

We found little evidence that people were harmed at the time of the assessment because the harm is not always immediate. However, people were placed at increased risk of harm because medicines were not always managed safely.