Charterhouse 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 72 (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 demonstrated a proactive and positive safety culture grounded in openness and honesty. Staff listened to safety concerns, thoroughly investigated issues, and consistently reported events, using lessons learned to identify risks and embed good practice.

A review of the provider’s lessons learned records showed clear documentation of incidents, the individuals involved, and consideration of how these events affected people, whether actions were right and fair, and whether there were any safety or professional concerns requiring further action. Records also included identified lessons, leadership insights, and feedback based on people’s experiences.

Staff described the atmosphere at Charterhouse Care Home as positive, with caring individuals who are motivated to learn and share their experiences.

The provider worked collaboratively with people and healthcare partners to develop and maintain safe systems of care, ensuring risks were effectively monitored and managed. They promoted continuity of care, including when people moved between different services.

People’s health conditions were clearly documented, and individuals were supported to access a wide range of relevant healthcare professionals. The provider ensured appropriate information sharing with external partners, including GPs and specialist nurses. Initial assessments completed when people joined the service contained detailed information about their needs, supporting continuity and consistency of care.

Professionals told us the provider was proactive in following up on actions identified during care reviews, effectively supporting people’s ongoing medical needs.

Staff had access to up-to-date information and demonstrated a good understanding of people’s individual needs, enabling them to provide safe and responsive care.

The provider worked collaboratively with people and healthcare partners to understand what being safe meant to them and how best to achieve this. Staff focused on improving people’s lives while upholding their right to live safely, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. Concerns were shared promptly and appropriately.

We reviewed records that demonstrated the effective and timely escalation, as well as detailed documentation, of safeguarding concerns. Staff had received relevant training and showed a good level of knowledge and understanding. Staff we spoke with were able to clearly describe safeguarding processes and their responsibilities.

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 MCA and how they managed DoLS within the service. We found that leaders demonstrated a clear understanding of when people may be subject to Deprivation of Liberty Safeguards (DoLS), and we saw that appropriate applications had been made. Leaders maintained oversight of DoLS applications that had not yet been granted. Any restrictions authorised under DoLS were clearly identified and followed by both leaders and staff.

The provider worked with people to understand and manage risks in a holistic way. Staff delivered care that was safe, supportive, and enabled individuals to do the things that mattered most to them.

Risks to people’s health, safety, and welfare were assessed, with care plans to manage these effectively. Plans were regularly reviewed and updated in line with changes to people’s needs. Staff had immediate access to up-to-date information through the electronic care planning system and were notified promptly of any changes. Records were maintained to demonstrate the support provided to manage risks, including repositioning and monitoring of skin integrity.

People and their relatives spoke positively about safety, with one commenting that there was a “firm focus on physical safety and emotional security.”

The provider assessed risks within the home and took action to ensure people, staff, and visitors remained safe. Personal emergency evacuation plans (PEEPs) wereto guide safe support during emergencies.

People told us the home was well maintained, and managers described a responsive maintenance system, with issues addressed promptly. Fire safety systems, water testing, and equipment such as lifts were regularly serviced and checked, with external specialists providing additional oversight.

Measures were applied to reduce environmental risks, including locked storage for hazardous items, alarmed external doors, and clear signage. Key information about people was securely stored to support effective emergency responses.

The provider ensured there were sufficient qualified, skilled, and experienced staff who workedeffectively together to meet people’s individual needs. The home was appropriately staffed, with a dependency tool used to determine staffing levels throughout the day and night.The provider ensured there were sufficient qualified, skilled, and experienced staff who worked effectively together to meet people’s individual needs. The home was appropriately staffed, with a dependency tool used to determine staffing levels throughout both the day and night. We found that the provider followed safe recruitment practices. Staff also received training relevant to their roles and to the needs of the people they supported.

Staff spoke positively about the culture, with one stating, “The environment is positive and supportive, with staff who are caring.”

People and their relatives also provided positive feedback, with one commenting that care staff had created a vibrant and safe environment as their relative’s condition declined.

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. Staff received comprehensive infection prevention and control (IPC) training and had immediate access to appropriate personal protective equipment (PPE). Regular auditing was embedded in practice, and staff displayed a strong and consistent understanding of maintaining high standards of hygiene.

The kitchen was well managed, with robust food safety systems, effective temperature monitoring, and safe handling practices in place. The local authority’s Environmental Health Department had issued a food hygiene rating of 5. Laundry arrangements were managed off-site, further reducing the risk of cross-contamination and promoting a safe, hygienic environment.

All areas of the home were clean, well organised, and maintained to a high standard. Equipment, furnishings, and high-touch surfaces were consistently managed to minimise infection risks. Clear and effective cleaning schedules ensured all areas, including bedrooms and communal spaces, were cleaned regularly and thoroughly.

The design and layout of the building supported best practice in infection prevention, including the effective management and isolation of outbreaks. Enhanced cleaning protocols and regular audits ensured standards were not only maintained but continuously improved. People consistently confirmed these high standards, with one person stating, “They always make sure everything is clean.”

The provider did not always ensure medicines and treatments were managed safely or in line with people’s needs, capacity, and preferences. Concerns included records being signed before medicines were given, unlocked medicine storage, gaps in temperature checks on one unit, and discontinued medicines remaining on records. Although systems such as policies, training, audits, and incident reporting were in place, oversight was not always effective. This meant medicines were not always managed safely.

These issues were raised with the manager on the second day of inspection, and immediate action was taken to address them. The provider had appropriate systems in place, including a medicines management policy, and staff were trained with up-to-date competency assessments. Medicines were available, in date, and stored appropriately, with temperatures usually monitored and high-risk medicines managed safely. Staff treated people with kindness and administered medicines correctly.