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Archived: Chestnut Lodge Care Home Inadequate

Inspection Summary

Overall summary & rating


Updated 17 September 2019

About the service: Chestnut Lodge Care Home is a residential care home that was providing personal and nursing care to up to 15 people aged 65 and over. 15 people lived at the home at the time of the inspection.

People’s experience of using this service:

Although most people and relatives told us they felt the home was safe, incidents including altercations between people were not always responded appropriately to, to help protect people from risk of harm and abuse. People’s risks were not effectively managed to keep people safe at all times. We identified a breach of the regulations due to serious concerns including around fire safety, the premises and managing people’s choking risks. The provider had failed to adequately learn from a choking incident and a person’s death in September 2018 and people were exposed to significant risk of harm. Medicines management and infection control processes were not consistently safe. We also found staff were not always suitably deployed to meet all people’s needs.

Although most people spoke positively about their care and staff told us they felt supported, people’s needs were not all effectively monitored and met. The provider had sought relevant training and had further training plans underway and often sought advice and input from healthcare professionals. However, this guidance and learning was not effectively shared with staff and embedded in people’s care in practice. Staff were not given clear guidance and information, to inform their knowledge and effective support to meet people’s needs. People’s risks were not always promptly escalated and shared with healthcare professionals to promote their health.

The provider had continued to improve the premises since the last inspection to ensure the home was safe and suitable for people. However, they had not fully considered people’s individual needs, for example, they had not addressed a recommendation we made at our last inspection to ensure the environment was tailored around the needs of people living with dementia.

People spoke positively about the food but were not involved in basic choices such as menu planning. The service was not working within the principles of the Mental Capacity Act and people’s choices and rights were not promoted as far as possible. Concerns identified at our last inspection had not been resolved, for example, people were still not routinely involved in decisions about their care. People’s independence was promoted, and we saw examples of how people’s diverse needs and preferences were recognised, however staff were still not consistently caring because people were not all treated with respect and dignity at all times.

People and relatives spoke positively about the home overall and people felt their needs were met. We saw examples of how some people’s individual needs and interests were considered in their care. Care planning and admissions processes had however failed to identify all people’s support needs and risks, and ensure these could be safely managed. The provider planned to improve their care planning processes including end-of-life care to ensure people’s needs and wishes were captured. There had been no complaints at the home, however relatives had submitted compliments.

People and relatives spoke positively about the provider’s welcoming approach. However, we identified a continued breach of the regulations due to the provider’s poor systems and oversight which failed to adequately assess, monitor and improve the service. The provider did not demonstrate sufficient understanding of good governance and had failed to identify significant shortfalls which put people at risk of harm. Sufficient improvements had not been made since the last inspection and despite previous enforcement action.

More information is in the full report.

Rating at last inspection: Requires Improvement (January 2018)

Why we inspected: We followed up on the provider’s last inspection rating and to follow up on e

Inspection areas



Updated 17 September 2019

The service was not safe.

Details are in our Safe findings below.



Updated 17 September 2019

The service was not effective.

Details are in our Effective findings below.


Requires improvement

Updated 17 September 2019

The service was not always caring.

Details are in our Caring findings below.


Requires improvement

Updated 17 September 2019

The service was not always responsive.

Details are in our Responsive findings below.



Updated 17 September 2019

The service was not well-led.

Details are in our Well-Led findings below.