Chestnut Lodge

On this page

• Overview
• Kindness, compassion and dignity
• Treating people as individuals
• Independence, choice and control
• Responding to people’s immediate needs
• Workforce wellbeing and enablement

Caring – this means we looked for evidence that the provider involved people and treated them with compassion, kindness, dignity and respect.

At our last assessment we rated this key question Requires Improvement. At this assessment the rating has changed to Inadequate. This meant people were not treated with compassion and there were breaches of dignity; staff caring attitudes had significant shortfalls.

This service scored 30 (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 treat people with kindness, empathy and compassion, or respect their privacy and dignity.

We observed some examples of staff being kind, patient, and supportive. On day 1 of the assessment, a staff member accompanied a person into the garden, allowing them time to walk without rushing them. Another staff member comforted a person who had become upset, holding their hand and offering reassurance before suggesting a walk, demonstrating warmth and compassion. Some people also told us they felt the staff were kind and most said the best thing about the service was the staff.

However, we observed interactions were not consistently positive, particularly with people who displayed behaviours that challenge. This was largely due to a lack of understanding and confidence rather than a lack of care. For example, a person who was distressed and was attempting to hit another service user was physically restrained by staff to prevent harm, and staff used themselves as shields to protect others. Despite their intentions, some actions, such as leaving a person on their hands and knees licking their fingers and rubbing the floor, compromised the individual’s dignity.

Additionally, 1 person did not have sufficient clothing or toiletries, despite leaders and the provider being aware of this since March 2025. The persons only expressed wish to improve their life was to have access to more clothes and personal items, which had not been addressed, leaving them feeling neglected and unsupported.

Management visibility on the units was limited, and there was no effective oversight of staff interactions, leaving people at risk of receiving undignified or inconsistent care. The combination of inconsistent practice, limited leadership oversight, and unmet basic needs meant that some people did not consistently experience care that was compassionate, respectful, or supportive of their dignity.

The provider did not treat people as individuals or make sure people’s care, support and treatment met people’s needs and preferences. The provider did not take account of people’s strengths, abilities, aspirations, culture and unique backgrounds and protected characteristics.

Staff did not consistently treat people as individuals and were often task focused. Group activities, such as Bingo, were delivered without consideration of the preferences of others in the communal areas, meaning some people were required to sit and observe rather than participate in ways that suited them. People with protected characteristics were not always recognised or supported according to their individual needs, and care plans lacked sufficient detail to guide staff in delivering personalised care.

Some bedrooms were bare and clinical, with little evidence of personalisation, and leaders had not addressed this between the last assessment and day 1 of this assessment, leaving people in environments that did not reflect their identity or preferences. One person told us they wished to have more frequent showers, but this was not consistently supported, and staff failed to record requests or refusals, leaving the person’s preferences unmet. Activities were not person-centred or tailored to the needs and interests of individuals, limiting engagement and wellbeing.

The lack of individualised care planning and recognition of personal preferences meant people’s choices and dignity were not consistently respected, leaving them at risk of feeling ignored, disempowered, and dissatisfied with their daily life.

The provider did not promote people’s independence, so people did not know their rights and have choice and control over their own care, treatment and wellbeing.

On day 1, people were offered limited choice in relation to food, drink, and activities. Although this had improved by day 2, communication barriers continued to prevent some people from having their preferences met. For example, a staff member asked a person whose first language was not English what they wanted for lunch. The person struggled to communicate their choice, and although the staff member said they would get help, no support was provided, potentially leaving the person’s preference unmet.

Visitors were welcomed at any time, but the service did not provide sufficient activity provision. Many people were left for long periods without meaningful engagement, particularly those in their bedrooms, who were at high risk of isolation. Records indicated that most people had spent no time outside and had fewer than 3 hours of activities recorded over a 28-day period, limiting opportunities for social interaction and personal development.

While some choices were offered, inconsistent support for communication and inadequate activity provision prevented people from consistently exercising independence and control over their daily lives.

The provider did not listen to or understand people’s needs, views and wishes. Staff did not respond to people’s needs in the moment or act to minimise any discomfort, concern or distress.

People had access to call bells, and those requiring regular safety checks were monitored according to records. However, care delivery was inconsistent, and some immediate needs were not met, resulting in harm. For example, 1 person required two-hourly repositioning, but this was not consistently provided, despite them having already developed deep tissue injuries. Between day 1 and day 2 of assessment, this person further developed moisture lesion, indicating their skin integrity needs were not adequately addressed, despite feedback from day 1.

Staffing levels on 1 unit was insufficient. When staff were attending to personal care in bedrooms, there was no one available to support people in the communal areas, leaving them without supervision and at risk.

While staff responded to falls, accidents, and incidents as recorded, omissions in routine care and inadequate staffing meant people’s immediate health and safety needs were not reliably met, placing them at risk of harm and deterioration in wellbeing.

The provider did not always care about and promote the wellbeing of their staff. They did not always support or enable staff to deliver person-centred care.

Staff were able to take breaks; however, deployment across the home created barriers, requiring staff to locate cover before leaving their posts. This impacted the smooth running of shifts and limited staff’s ability to take uninterrupted breaks, potentially affecting their wellbeing and capacity to provide consistent care.

Staff told inspectors they felt supported in their roles and could raise concerns with leaders. Despite this, there was limited evidence of initiatives or structured support in place to promote workforce wellbeing or development. There was inconsistent support for staff, combined with deployment challenges, which negatively impacted staff morale, and indirectly affected the quality and safety of care provided to people.