Chaucer 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 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 safeguarding people from abuse and harm, safe and effective staffing and managing people’s health risks.

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.

Incidents and were not appropriately investigated and reported. We identified 12 incidents between people that had not been recorded as an incident by staff, in the last 3 months. For example, one incident detailed one person had physically assaulted another person. Another incident detailed one person was entering the room of another person whilst they were receiving personal care and staff were unable to support the person to leave the room, this led them to become physically aggressive.

Where incidents had been reported by staff, the information was limited which meant a full analysis could not be done effectively. Whilst the provider did have systems in place to report incidents, this was not effective as staff did not always report incidents.

Lessons were not learnt following incidents. Incidents which were recorded on an ‘ABC chart’ had not been reviewed to assess if actions could be taken to mitigate the risks to people and to prevent reoccurrence. An ABC chart is a structured observation tool used to record and analyse challenging behaviour by documenting what happens Antecedent (before), Behaviour (during), and Consequence (after). It helps caregivers identify triggers, understand the reasons behind behaviour, and develop strategies to support positive behavioural changes. This meant that lessons were not learnt and therefore changes could not be implemented to make improvements.

Staff completed a survey which highlighted concerns in relation to the learning culture at the service. One question asked in the survey was ‘When mistakes happen, the focus is on learning not blame’, over 60% of the responses fed back negatively. This suggests more than half of the staff team felt following incidents there was a ‘blame culture’ rather than learning.

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.

The provider had not ensured that referrals to other healthcare professionals were consistently actioned. The provider had systems in place to make referrals; however, these were not effective to ensure staff identified and escalated where a referral may be required. For example, staff had not reported an unexplained bruise which meant there was a delay in medical attention being sought. Once the person had been supported to seek medical advice, it was found they had sustained a significant fracture.

When the provider was aware of health concerns, referrals were made to the relevant health care professionals such as tissue viability nurses to support with wound care.

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.

The provider failed to ensure they safeguarded people from harm and abuse. Whilst the provider had systems in place to escalate safeguarding concerns, these were inadequate. We identified incidents where one person had physically and verbally assaulted another person on more than one occasion. Staff had not identified these as potential safeguarding incidents and therefore, they were not reported as such. Staff also failed to report and escalate incidents of unexplained bruising. One incident of a significant unexplained bruise was identified by a family member and had not been identified by staff. Staff supported the person with personal care every day and had failed to document or escalate the unexplained bruise.

Where applicable, Deprivation of Liberty Safeguards (DoLS) had been completed and notifications had been submitted to the CQC. DoLS are important human rights safeguards; they aim to ensure that such deprivation of liberty only happens when it is necessary, proportionate and in the person’s best interests.

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.

The provider had not managed people’s health risks relating to constipation, skin integrity and distressed behaviours. One person was at risk of constipation and was prescribed laxatives to support them if they became constipated. The person’s care plan detailed staff should intervene after 2-3 days of no bowel movement. Care records showed that staff did not intervene and administer laxatives until day 4. Staff had not ensured they followed guidance to support the person when they became constipated.

People who were at risk of developing pressure ulcers, or had active pressure ulcers were not supported by staff who followed the guidance in place. One person’s care plan detailed they had a strict repositioning protocol to support healing of pressure ulcers and prevent deterioration. The person’s guidance detailed they should be supported to reposition every 2 hours. The persons care records detailed this was not happening, we identified gaps of over 19 hours where they had not been supported to reposition. This placed the person at increased risk of their pressure ulcers deteriorating and developing new pressure ulcers.

People who experienced distressed and anxious behaviours did not have effective guidance in place for staff to follow. One person would frequently become distressed and be involved with physical and verbal incidents towards other residents. The person’s care plan did not detail how staff should support the person when they became aggressive or how to safeguard other people. We identified multiple incidents where this had occurred and the records detailed staff did not have effective guidance to support them. Incidents detailed, ‘all attempts to get person to leave the room, while the other person was asleep, were futile’ and ‘both people have been separated as they get into fights easily, resulting in punches.’ Care plans did not detail what staff should do in emergency situations and when incidents between people escalated.

The provider did not always detect and control potential risks in the care environment. The provider had not considered how environments can keep people safe from psychological harm as well as physical harm, for example in relation to sexual safety.

We identified incidents where people were able to access other people’s bedroom without consent. One person displayed sexually inappropriate behaviours towards other people. Whilst the provider had implemented a 1-1 staff member during the day, incidents still occurred during the day and the person had accessed another person’s room on 2 occasions and inappropriately touched them without their consent. The provider had not considered other environmental mitigations to keep people safe from the risk of harm.

We found another person accessed a resident’s room while they were receiving personal care. Incident records detailed this happened on multiple occasions and staff were unable to remove the person from the room due to them becoming physically and verbally distressed. The provider had not mitigated the environmental risk of the person being able to access the unlocked bedroom, leaving the person at risk of physiological and physical harm.

Potential trip hazards in people's rooms had not always been identified. For example, in some rooms we noted wired which presented a falls risk.

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 together well to provide safe care that met people’s individual needs.

Staff had not received training that was appropriate to their role. For example, staff supported people that expressed distressed and anxious behaviours, records showed that nearly half of the staff team had not completed training in positive behaviour support. We found that staff were not competent to support people during periods of distress.

Staff were not competent to support people with pressure care. We found staff were not supporting people in line with their skin integrity guidance. Staff were not competent in their role in relation to incidents and accidents. We identified incidents, including potential safeguarding incidents, that had not been reported and escalated by staff.

Staff we spoke with told us they did not have regular supervisions. Staff told us they did not always feel supported by senior leaders to carry out their role.

Staff were recruited following safe recruitment practises, for example the provider ensured staff had a valid DBS check. Disclosure and Barring Service (DBS) check is a background screening used to ensure individuals are safe to work with vulnerable adults and children.

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.

Parts of the service were highly odorous including people’s bedrooms and communal areas. Whilst the service was mostly clean, some areas were not well maintained. For example, seats within the dining room were highly stained and in need of cleaning / replacing. Some chairs within people’s bedrooms were also in need of replacing.

There was one domestic staff member per floor and they worked to ensure that the service was clean, focusing on deep cleaning a person’s room and high touch areas regularly.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. The provider did not make sure that people received their medicines in line with prescriber guidance. For example, some people were prescribed time sensitive medicine for Parkinsons, these were not consistently administered within the required time frame. Delays in medicines for Parkinson’s disease significantly increases the risks and symptoms associated with Parkinson’s disease.

The provider failed to ensure ‘as required’ medicines were administered in line with the prescribers guidance. For example, one person was prescribed ‘as required’ medicine to support with distressed behaviours. The guidance stated to not administer the medicine after 4pm. On 4 occasions in April this medicine was administered after 4pm, one incident being after 9pm. Staff also failed to document when and why they were administering the ‘as required’ medicine. The administration of the ‘as required’ medicine did not coincide with daily records to reflect that this was the last resort to support the person.

The provider failed to ensure prescribed thickener was being used appropriately. Thickener is a substance used to change the thickness of a fluid to support people who have difficulties swallowing. We found 3 people were prescribed thickener, however we found that only 2 people had thickener in the cupboard, 1 of which was empty. There was also no record of the thickener being used in drinks. Staff were not recording when they were making a drink for a service user and how much thickener was being used. We could not be assured that thickener was not being shared between people or how much was being used for each serving.

The provider had not ensured prescribed creams and ointments were well managed. People living with dementia had access to medicated creams without these being locked away.Medicated creams had labels removed and were not being used for the specific person they were prescribed for.We found one person’s creams in another person’s room.This was misappropriation of people’s medicines.