Charnley 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

Accurate and contemporaneous records were not always maintained in a number of areas. This included re-positioning charts and the documentation of people’s food and fluid intake.

Where people required their drinks to be thickened due to being at risk of choking, inconsistent records were maintained by staff. Care plans were not always updated when people’s care needs changed following advice from the SaLT (Speech and Language Therapy) service.



Some risks weren’t effectively managed. Items such as aerosols, shower gels and creams were not always stored safely. One person had been observed trying to eat these items which could place them at risk of harm. People weren’t always provided with pressure relieving cushions to ensure they maintained good skin integrity.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People living at the home and their relatives said appropriate actions were taken when incidents occurred, or concerns about safety. One relative said, “They moved (person) down to a room on the ground floor to better manage (person) as they wander about at times, but they asked me first if they were ok to do that. I have nothing but praise for them and nothing to say that is negative.”

The management team regularly analysed accidents and incidents to identify any emerging themes or patterns in order to improve the care provided. These findings were then shared with the staff team. Staff confirmed they were informed of any actions following an accident or incident through the daily meetings that took place. Staff handover took place where any concerns about a person’s safety could be discussed.

Where people had an accident or incident, this was recorded, monitored and action taken to address concerns. Analysis of incidents was also undertaken so that any trends could be monitored.

We didn’t receive any feedback from people living at the home in this area.

The service worked in partnership with other professionals such as GP's and dietitians to support people to access healthcare when they needed it. This had improved people's outcomes. The management team and staff demonstrated how when a person's needs had changed, they had promptly engaged with several services to ensure the person's needs were fully met and understood.

We didn’t receive any feedback from partners in this area.

We reviewed the providers admission process and found key information was sought from the person, their relatives and any external professional involved in the person’s care to enable a positive transition into the service. We also found the assessment continued following their admission to ensure the staff had accurate and up to date information on people's needs and preferences. However, care plans weren't always updated to reflect changes to people's care needs.

People living at the home and relatives told us they felt the service was safe. One person said, “I feel very safe here. It’s fine in here I am happy to be here and all the girls are nice I can't grumble I have no problems. The staff look after me well, but if I had any concerns I would feel happy to talk to any of them.”

Staff understood about safeguarding and how to protect people from harm and had received safeguarding training.

During the assessment we observed staff treating people well and safely. Any moving and handling transfers were completed safely.

There was a safeguarding policy and procedure in place which was in date and provided an overview about what people could do if they experienced any abuse.

A safeguarding log was maintained, with details about any incidents reported to the local authority for further review.

Staff had completed safeguarding training, although we noted some newer members of staff still needed to completed this when we reviewed the training matrix. We were told plans were in place for this to be completed.

People living at the home and their relatives told us they were involved in managing risks and care planning, although their experience could be compromised due to some of the concerns we identified regarding risk management processes.

Staff understood about people’s care needs and the risks presented to them. For example, people who may be at risk of choking, or skin breakdown.

We saw staff responding to people’s needs in a safe way during the assessment.

At our last inspection of the service in August 2023, we identified a breach of regulation 12 regarding safe care and treatment. Although some of the areas of concern had been addressed, some remained.

Where people’s care plans indicated they needed to be re-positioned every 2-4 hours, accurate records were not maintained to demonstrate this was completed by staff. Some people were not always seated on pressure relieving cushions, as described in their care plan.

Records maintained by staff regarding thickened fluids were inconsistent and not always in line with guidance from the speech and language therapy (SaLT) team. One person’s care plan had not been updated to reflect changes to their nutritional needs.

There were gaps in people’s nutritional charts and where people required nutritional supplements due to losing weight, accurate records were not maintained. Some people’s fluid charts indicated very low amounts of fluid were offered on certain some says, however we did see plenty of drinks being served during the inspection.

One person had a risk assessment stating they were at risk of eating items such as shower gel and that they should be removed from the bedroom and stored securely in the office. Items were also in other people’s rooms which were not locked away and we observed this person to be mobile around the home unsupervised, which could place them at risk of harm.

Some ‘Fire door keep locked’ doors were not secure. Arrangements were made for this to be done during the inspection.

At our last inspection in August 2023, some radiators did not have guards on them and wardrobes were not secured to the wall which meant they could fall on people. With the exception of one radiator (which was not hot) in the home, we saw guards had now been installed to reduce the risks of burns and scalds. We were told this had previous been removed by a resident living at the home.

People living at the home and their relatives said the felt the home environment was safe, although we found unsafe items weren't always stored securely, such as toiletries in people's bedrooms.

Staff spoken with during the inspection told us they felt the home environment was safe, secure and well-maintained.

We walked around the building and to ensure if was well maintained and safe for people to live in. We didn’t identify any concerns following these observations, although we have reported further about the appearance of some carpets within the infection control section of this report.

The building was safe and we viewed certificates of maintenance work completed around the home. Portable appliance testing (PAAT) had expired, although arrangements were being made for this to be undertaken. People's toiletries weren't always stored safely and presented the risk of wrongful ingestion.

People living at the home and relatives said there were enough staff to care for them safely and that staff had the correct skills to carry out their work. One person said, “There always seems to be enough staff about to care for our needs.” A relative added, “There always appears to be enough staff around and I do think they seem well trained in the job that they do.”

Overall, the feedback we received was that enough staff were available and that people’s care needs were met. Staff said they received relevant supervision and appraisal, although these had not been completed for some newer members of staff. We were told plans were in place for this to be completed.

We observed there to be sufficient numbers of staff available during the assessment. We saw people being assisted by staff in a timely way and didn’t see anybody waiting unacceptable amounts of time for assistance.

Staffing rotas were in place and this demonstrated how many staff were required to care for people. A dependency tool was also used to determine how many staff were required.

Staff were recruited safely with the necessary pre-employment checks carried out. Staff received regular training, supervision and appraisal to support them in their role. At the last inspection, some training had not been completed including Catheter care, End of life, Dementia, Learning disability and autism, Consent, MCA/DoLS and Dignity and Respect. We noted some staff had completed this training, although according to the training matrix, some updates were still required. We were told plans were in place for this to be completed.

People living at the home told us felt the home was clean. One relative said, “Its always clean and tidy when we visit.”

Staff spoken with during the inspection told us they felt the home environment was clean and tidy.

We noted that in some bathrooms, sinks weren’t available. This meant people would not be able to wash their hands before unlocking the door. The provider had explored the option to change this however had determined people who were more independent could be restricted from using the toilet due to handrails on both walls for people to use to stand up. They also felt a sink could restrict movement for people who use zimmer frames as the space within the toilet would be restricted as a result of a potential change.

Some carpets were also dirty and would benefit from being replaced, particularly on stairwells. We were informed by the management team that these were due to be replaced.

Appropriate systems were in place to ensure safe infection control standards were maintained. We found the home to be clean and tidy and observed domestic staff carrying out their duties during the assessment. No odors were present in any parts of the home. Cleaning schedules were in place. The home had received an overall score of 97% following their most recent infection control audit.

We saw staff encourage people to take their medicines in a patient and kind manner.

We saw people on high-risk medicines had regular risk assessments and reviews to ensure the medicines were safe and effective.

There was a person-centred approach to support people to have their ‘when required' medicines when they needed them. The outcomes of when ‘required medicines’ were assessed and recorded to ensure they were effective.

Whilst staff demonstrated good knowledge of people’s medicines needs, care plans did not always have up to date information about how to support people with their medicines.

Staff provided evidence demonstrating that delegated healthcare tasks (for example, insulin administration) were managed safely.

Medicines incidents were recorded, analysed, and learnt from.

Managers told us that staff had completed medicines training and had been

assessed to ensure that they gave medicines safely. We were shown evidence of training records to confirm this.

People’s allergies were accurately recorded. Medicines were stored safely and stock levels recorded accurately. This included controlled drugs.

For people with swallowing difficulties who had thickening powder added to drinks, there was a process to ensure that they were given, stored and recorded safely.

We saw one person was having their medicines given covertly (hidden in food or drink). However, advice from an appropriate healthcare professional had not been sought about how to administer them safely. Since the assessment, the service has provided evidence that this is now in place.

Nutritional supplements were not always recorded accurately and consistently when given to people. There was a risk that they were not being given as prescribed.

Robust processes for recording the application of creams were not always in place. There was a risk they may not have been applied as prescribed.