Chestnut Lodge

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 Inadequate At this assessment the rating has remained Inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to failing to safeguard people from potential harm or abuse, safe care and treatment, the ways people’s medicines were managed, safe environments, and safe and effective staffing.

This service scored 31 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Staff failed to complete accident, incident, and Antecedent-Behaviour-Consequence (ABC) records robustly and consistently, meaning that for some reportable safety events, critical details were not captured or, in some cases, not recorded at all. This incomplete documentation limited the ability of managers and leaders to review incidents effectively or identify patterns that could prevent future harm. There was no clear oversight or review of ABC and incident records, and no evidence that lessons had been learned or improvements implemented in response to reportable events.

As a result, risks to people were not systematically identified or mitigated, leaving individuals exposed to avoidable harm. The absence of structured learning from incidents demonstrated inadequate oversight and a failure to maintain a culture of safety, accountability, and continuous improvement, which compromised the overall safety and well-being of people living in the home.

Systems to support safe pathways and transitions required improvement. Partnership working with healthcare professionals while people were in the service was not always effective, and we saw delays in gaining professional input when people’s conditions changed. This meant people were not always supported to receive timely interventions to meet their needs.

However, the provider worked with people and healthcare partners to promote continuity of care, including when people moved between different services. The pre-admission policy was followed. For example, in a recent admission we reviewed, comprehensive and timely assessments had been completed prior to admission. These clearly identified the person’s needs, preferences and risks, which enabled a smooth and safe transition into the service.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

Although a safeguarding policy was in place, we identified serious and repeated failures in protecting people from harm or abusive behaviours. We found multiple incidents that met the threshold for reporting but had not been recorded or escalated appropriately. Examples included a person being restrained to have blood taken without clear evidence of best-interest decision-making, and physical altercations between service users. The provider was not aware of the incident relating to restraint; following a review of the incident staff were suspended.

Staff did not consistently recognise behaviours as potential abuse and failed to consistently document these concerns in care and incident records. This meant patterns of risk were not identified, and opportunities to prevent harm were missed. In some cases, care records incorrectly stated that a person was content, despite them displaying distress and behaviours that challenged, leaving them without the support they needed.

These safeguarding failures placed people at ongoing risk of harm. As a result of concerns identified on the first day of assessment, we made safeguarding referrals for 8 people to the local authority to ensure immediate protection.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks were not consistently managed in a safe manner. Repositioning records were inaccurate, and staff were observed not repositioning people in line with their assessed needs, despite documenting otherwise. This was seen repeatedly across both assessment days, indicating a systemic issue rather than isolated errors. Care records were often inaccurate and, in some cases, contradictory. For example, one person’s care plan stated they could walk independently in 1 section but elsewhere indicated they could not. The same person’s care plan advised staff to mitigate fall risk by ensuring suitable footwear; however, on both assessment days, they were observed walking in socks. This exposed the person to a significant risk of falls and injury, with no evidence that action had been taken to address it.

Risk assessments were not robust. One person with behaviours that challenge had a risk assessment in place, but it lacked practical guidance for staff on how to respond safely to physical challenges, placing both staff and the individual at risk of harm. Antecedent-Behaviour-Consequence (ABC) charts were incomplete and had not been reviewed by managers or service leaders for several months. As a result, incidents were not fully documented, debriefs did not occur, and there was no evidence of reviews to identify learning or implement preventative measures.

These failures meant risks were not effectively mitigated, leaving people exposed to avoidable harm and demonstrating inadequate oversight of care practices.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The environment was not consistently safe, placing people at risk of harm. On day 1 of the assessment, the door to ground floor unit did not close properly or lock. Staff were aware but had not reported or addressed the issue, leaving people vulnerable to unauthorised access. Nurses’ offices were unlocked and contained hazardous materials, increasing the risk of accidental injury. In the service we found holes in the ceiling, exposed screws from removed light fittings, and broken trunking posed further safety hazards. An out-of-use lift was being used while inspectors were present, creating potential risk to users. Many ensuite bathrooms were used to store equipment or continence products, restricting access and increasing the risk of slips and trips.

On day 2 of the assessmentsome improvements were observed, but hazards remained. The medicines stock room on the ground floor was left ajar, giving unrestricted access to return medications and sharps containers, which could result in accidental or intentional harm. The door leading to a unit on the first floor was not locking, requiring immediate maintenance intervention to prevent unauthorised access. In another unit which was being decorated, a radiator cover was removed and left on the floor while staff and residents moved around, creating a hazard.

These environmental failings placed people at significant risk of physical harm and demonstrated inadequate oversight and unsafe practices by staff.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work well together to provide safe care that met people’s individual needs.

A recruitment policy dated 18 November 2024 was in place, but the policy had not been consistently followed, and the provider had not assured themselves within a reasonable time frame that all staff had the necessary pre-employment checks since a new managing company took over. Multiple shortfalls were identified in staff recruitment files. For example, 1 staff member had a warning on their DBS, but there was no evidence the provider had investigated the nature of this warning, leaving people at risk of being cared for by unsuitable staff.

Staffing levels on 1 unit were not sufficient to safely meet people’s needs or respond effectively in an emergency. While staffing was increased on day 2, deployment issues persisted. For instance, during lunch, the second staff member on the same unit was redeployed to another unit, leaving only 1 staff member again on the unit, placing people at increased risk of harm.

Relatives told us they did not feel there was always sufficient staff. One relative told us, “I do not feel there is enough staff to safely care for [person], on an evening in particular there is not enough staff.” Feedback from other relatives also included, “I have seen other residents fall and there were no staff in the lounge” and “One resident picked up a vase and was going to throw it, so I stopped it as there was no staff around.”

The staff training matrix indicated compliance; however, there was no assessment of competency or observation to ensure that training was understood and implemented safely. Staff reported feeling unsure how to support people living with dementia and expressed a need for additional training and supervision.

These failings placed people at significant risk of harm due to unsafe recruitment, insufficient staffing, and inadequate support and oversight of staff practice.

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.

On the first day of assessment, malodours were detected in several areas of the home, particularly near or in people’s bedrooms. One person’s mattress had a strong odour of urine, indicating that cleaning practices and bedding management were not consistently effective. By day 2, the environment was cleaner and the odour from the mattress had reduced; however, in one resident’s bathroom, staff had left a used continence pad on the floor along with their gloves, presenting a risk of cross-contamination and infection.

Staff were observed wearing personal protective equipment (PPE) correctly during mealtimes and when assisting people, demonstrating adherence to infection control procedures in some areas. Despite this, the inconsistencies in cleanliness and management of contaminated items placed people at risk of avoidable infection.

People were not consistently supported to take their medicines safely, and records did not always provide a rationale or evidence of effective administration. For example, 1 person received ‘when required’ (PRN) medication 11 times between 2 and 28 July 2025, but their care notes, incident reports, and ABC records did not support the timing or reason for all these doses, and no record was made of the effectiveness of the medication.

Some medicines were not administered for prolonged periods, placing people at risk of harm. A pain relief patch prescribed on 4 July 2025 for a person, was not followed up until 18 July, and by 28 July the person had still not received it. Following intervention from the medicine’s inspector, it was clarified that the GP had prescribed liquid pain relief instead, which had been available from 7 July, meaning this person went over 21 days without appropriate pain relief. Lansoprazole, a medicine used to reduce the amount of acid made in the stomach, was not administered between 2 and 28 July 2025 for another person. As well as this we found Senna, a medication prescribed to treat constipation, was not given in line with prescriber instructions, resulting in the person going 7 days without a bowel movement.

Thickening agents used to reduce the risk of choking were not being consistently recorded, so there was no assurance they were administered with every drink for a person in line with their assessed needs. A nurse confirmed thickening powders were only recorded on fluid charts when a person was on fluid watch, leaving significant gaps in evidence that people were receiving safe care.

However, staff had received training in medicines management and competency checks had been completed. Allergies were also clearly recorded on the medication administration records. Despite these measures, failures in administration and recording placed people at substantial risk of avoidable harm, including unmanaged pain, discomfort, and potential complications from missed or incorrect medicines, demonstrating inadequate oversight of medicines management and unsafe practice by staff.