Chestnut Lodge

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question Requires Improvement. At this assessment the rating has changed to Inadequate. This meant there were widespread and significant shortfalls in people’s care, support and outcomes.

This service scored 25 (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 make sure people’s care and treatment was effective because they did not check and discuss people’s health, care, wellbeing and communication needs with them.

We reviewed 8 people’s full care plans, including supplementary charts, daily records, and risk assessments, as well as parts of a further 12 people’s records focusing on incidents, ABCs, repositioning and elimination monitoring. While care plans were reviewed monthly as routine, there was no clear evidence that people or their representatives had been involved in the creation or review of their plans. People had not signed their care plans, and information was not consistently captured from their perspective or in line with their preferences, meaning records did not reliably reflect their individual needs.

Daily care records kept by staff were not always accurate or reliable, with several occasions where records did not reflect a person’s presentation, mood, or assessed needs. As a result, there was a risk that care was not fully tailored or responsive, and people could receive support that did not reflect their preferences or changing requirements. The lack of meaningful involvement in assessments and inconsistent recording placed people at risk of care being less effective and not fully meeting their needs.

Although assessments and care plans were completed and reviewed regularly, the absence of person-centred involvement and inconsistent record-keeping compromised the effectiveness of care. Several people confirmed they had not seen their care plan and were not involved in reviews. This reduced their ability to make informed decisions about their care and support.

The provider did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards.

Clinical monitoring tools were in place, including Waterlow risk assessments, Positive Behaviour Support risk assessments, and nutritional assessments. However, these were not consistently linked to people’s care plans, and there was no effective oversight to ensure that the resulting charts were used or reviewed appropriately. For example, people assessed as requiring ABC charts did not have these reviewed or considered during the monthly review of their risk assessments.

Where people had lost weight and were on food intake charts, there was no systematic monitoring or analysis of records to ensure that nutritional intake was sufficient. Similarly, for individuals assessed as very high risk on their Waterlow assessment, repositioning records were not routinely reviewed, and checks were not consistently performed to confirm that staff were meeting assessed needs and maintaining skin integrity.

These gaps in monitoring and linking assessments to care planning meant that care delivery was not reliably informed by evidence, placing people at risk of harm, including malnutrition, skin breakdown, or unmanaged behaviours. The absence of effective oversight undermined the use of clinical tools to support safe and responsive care.

The provider did not work well across teams and services to support people. They did not share their assessment of people’s needs when moving between different services.

Pre-assessments were robust, supporting effective transitions into the service. However, information sharing within the service was inconsistent and unreliable, resulting in care staff not always being aware of people’s individual needs. For example, 1 person had a night bag to support incontinence in place during the day, a decision made by a nurse but not recorded in the care plan. On day 2, a staff member supporting this person told us they were unfamiliar with the persons specific catheter needs. In another instance, a person had been prescribed Oramorph, which had been received by the home, but the nurse in charge on both assessment days was unaware of this, placing the person at risk of missed pain relief.

Communication between partners, managers, and leaders was also ineffective. Incidents, such as the one involving restraint, were not shared openly within the leadership team. Following local authority visits and the assessment on day 1, the feedback provided to senior leaders differed from what was communicated at the end of the visits, indicating a lack of openness and transparency.

These failures in communication and teamwork increased the risk that care would not be delivered safely or in line with people’s assessed needs, undermining staff coordination and exposing people to avoidable harm.

The provider did not support people to manage their health and wellbeing, so people could not maximise their independence, choice and control. Staff did not support people to live healthier lives, or where possible, reduce their future needs for care and support.

We saw evidence that other professionals were involved in people’s care, including GPs, SALTs, chiropodists, dentists, mental health teams, and some falls referrals. However, support for people to maintain healthier lifestyles, particularly with personal hygiene, was inconsistent. On day 1 of the assessment, we found some people’s toothbrushes dry, crusty, or brand new never used, and many people told us they did not receive regular support to brush their teeth. While this improved on day 2, documentation consistently indicated that hygiene support had been provided daily, suggesting records were not always accurate.

Additionally, people at risk of developing pressure damage were not consistently supported with pressure care, placing them at risk of harm. These gaps in support meant that people’s health and wellbeing needs were not consistently met, and there was a risk of preventable deterioration in their physical health.

The provider did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

People’s care and support were reviewed monthly; however, there was no evidence that these reviews were conducted with the person or their representatives. Many records contained inaccurate or inconsistent information, undermining the reliability of care planning and oversight.

There was no evidence that people had been supported to develop skills, maintain independence, or improve their quality of life. This was particularly evident for people displaying behaviours that challenge, where no action had been taken to address concerns or improve outcomes. Staff reported a lack of confidence in supporting people with dementia who displayed challenging behaviours, with some stating they felt there was nothing they could do to support the person during these episodes.

These failures in monitoring and improving outcomes placed people at risk of stagnation or deterioration in their health, wellbeing, and independence, and demonstrated a lack of proactive management to reduce harm or enhance quality of life.

The provider did not tell people about their rights around consent and did not always respect their rights when delivering care and treatment.

Consent was not consistently recorded in people’s care records in relation to ongoing care and treatment. Records did not demonstrate that people had agreed to the information documented about their care or the specific care interventions they required. While staff did gain verbal consent before providing care or support to people in communal areas, the absence of formal, recorded consent meant there was no clear assurance that people’s rights and preferences were consistently respected.

This lack of recorded consent increases the risk that care may be delivered without a person’s knowledge or agreement, potentially undermining their autonomy and placing them at risk of receiving care they have not agreed to.