Chetwynd House

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 changed to 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 provider was in breach of regulation in relation to safe care and treatment.

This service scored 53 (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. Lessons were not always learnt to continually identify and embed good practice. Professionals who worked with the service such as the local authority and Integrated Care Board had raised concerns and areas for improvement repeatedly to the management team regarding care planning and medicines management. However, lesson learnt had not been consistently shared with staff and improvements had not been implemented effectively or safely.

We discussed this concern with the provider who were open and honest about the areas needed for improvement and they had an action plan in place which included a new management team to ensure lessons learned were reviewed an implemented going forward.

The provider did not always 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. Care plans did not always contain guidance and recommendation received from professionals such as district nurses. For example, 1 persons’ care plan stated they needed to have their blood sugar level checked regularly. There was no further guidance for staff on when or how often this should be done during each day. This place people at risk of harm from higher blood glucose levels which can lead to additional health complications.

We observed people being supported by staff in a person-centered way during their admission to the home. Staff spent time with the person, orientating them with the home, introducing them to people and understanding their needs. This placed the person at ease and helped their transition into the home feel safe and secure.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Staff were knowledgeable about safeguarding and received regular training to ensure their skills were maintained. Staff we spoke were knowledgeable about risks specific to people living at Chetwynd House and were confident to raise concerns if needed. One staff member said, “Despite changes in management, I know everyone is safe. We all take safeguarding so seriously and I would raise my concerns externally instantly if I thought the managers were not doing anything, but they are so proactive and supportive. Residents and staff are always listened to.” We saw evidence that supported staff feedback as incidents had been logged and reported to the local authority and CQC appropriately. Incident were also monitored and followed up prior to a safeguarding needing to be raised. This kept people safe and improved their outcomes and experience.

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 and supportive. Care plans did not contain clear or update guidance for staff on the level of support people needed. For example, 1 persons’ care plan said they needed support with repositioning to prevent pressure damage. There was no guidance for staff on how often this support needed to be provided to keep the person safe. Another person’s care plan stated they were at risk of weight loss and needed to have their fluid and nutrition recorded daily, however staff failed to consistently record this information. Where gaps in recording or missed fluid and nutritional target had occurred there was no evidence this had been escalated to management or other professionals to ensure the person remained safe.

The provider did not always detect and control potential risks in the care home environment. They did not always make sure equipment supported the delivery of safe care. For example, during the assessment we observed crash mats within people rooms that were dirty and stained. Additionally, some crash mats were damaged and ripped which reduced the effectiveness and safety of the equipment. Within communally areas we observed some pressure cushions to be visible dirty and stained. Pressure cushions were not labelled or identifiable so despite audits being in place we could not identify when checks on each item had last taken place. We discussed these concerns with the management team who took immediate action and rectified the issues we identified on the day of the assessment and ensured all equipment was clearly labelled to prevent the risks reoccurring, and damaged or stained items were replaced.

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. Staff were recruited safely, and appropriate checks such as references and disclosure and barring checks were undertaken prior to staff commencing employment. Staff and residents had raised feedback about staffing levels in the evening. The management responded quickly and increased staffing level until midnight each day to ensure people received their care safely and responsively. Staff we spoke with told us they felt supported and valued by the provider. One staff member said, “Despite the management changes I have still had training and my supervisions. The whole management team are approachable and very quick to help or look into any concerns.”

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. During both days onsite during the assessment infection, prevention and control (IPC) concerns were identified. For example, staff did not wear personal protective equipment (PPE) such as gloves and aprons when serving food or supporting people to eat. This increased the risk of harm to people from cross contamination of infection as hands can carry pathogens from surfaces, equipment, or other people. Additionally, some staff wore jewellery, including rings, bracelets, and necklaces. This posed a further risk of cross contamination. These concerns were feedback to the management team, who immediately put an ongoing action plan into place to ensure IPC was improved, staff were also given refresher training in IPC including handwashing.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. External audits completed by other professionals who visited the home had highlighted issued that remained on this assessment. This showed the provider had failed to act on feedback and improve medicine management and safety. For example, the provider failed to ensure the Controlled Drugs (CD) register was completed accurately and in accordance with legal and regulatory requirements of the Misuse of Drugs Regulations 2001. The register contained missing dates and times that medicines had been administered, and some entries had been crossed out with following the protocols in line with best practice. Additionally, we identified some people had an excessive stock of medicines stored within clinic room and stock totals for some people medicines were not accurate. Furthermore, records showed that some people did not receive their prescribed medicines in line with the manufacturer’s guidance. Some medicines stated people needed to take prior to food and we consistently saw this medicine was given with or after food. This meant we could not be assured people had received their medicines in line with their prescribed dosage or timeframe which place them at risk of harm.