Chipstead Lake - Care Home Physical Disabilities

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

People were not kept consistently safe and there was not always a positive learning culture. There had been incidents within the service involving people and placing them at risk. These incidents had not always been recorded and used as a learning opportunity to reduce the risk of them happening again. Some incidents had not been identified as being a possible safeguarding concern, the incidents had not been reported to the local authority as required. People’s care plans were not always accurate and did not contain the relevant information staff needed to support people safely. Medicines were not always managed safely. There were enough staff to meet people’s needs, however, there had been a recent high turnover of staff and there continued to be a couple of vacancies. Staff knew people well and understood their physical and communication needs. We observed positive interactions between people and staff.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People were not always supported to remain as safe as possible. Identified risks had not always been reviewed or guidance put in place to reduce the risk. One person's risk assessments had not been reviewed or updated following incidents where they were distressed. There was no guidance for staff to support the person to manage their distress and risks. When incidents had occurred these had not been recorded or used as a learning opportunity to improve the person's experience of living at the service. The person continued to experience these negative feelings placing them at risk of harm.

Staff told us that they would be confident to raise concerns and felt that action required would be taken. We were told, “I brought up concerns in the last couple of weeks and they were dealt with straight away. I’d flag the issue with a message in (registered manager's) post box and it was dealt with when I came in on Monday afternoon.”

There were no effective systems in place to promote a learning culture. Accident and incident recording was poor and there was evidence that not all accidents and incidents had been recorded and monitored appropriately. The registered manager told us of incidents in relation to one person. These included the police being called on one occasion before the registered manager was in post. An incident report had not been completed and the registered manager was unable to provide any details as records were not available. We were also told of incidents that had happened more recently when the person had kicked a member of staff and grabbed the arm of the registered manager. This had not been recorded as an incident. Therefore lessons had not been learnt as the details of the lead up to incidents, what happened, and how they could have been prevented were not evident. Incidents were not investigated to identify a root cause which put people at a continued risk of harm.

People had not always been supported to develop skills and move from the service as intended. A relative spoke to us about their loved one's experience, they had not been supported to be able to move out of the service. They explained staff had not supported them with preparing meals when they were living in a flat linked to the service. The person had needed to come back into the main house for meals.

Staff told us about supporting a person to move into the service from another of the provider’s service. They had a handover from the staff teams who supported them previously.

Partners we spoke with did not have any feedback on this quality statement, there were no concerns raised.

People who were admitted to the service did not have an assessment completed by Chipstead Lake staff. There were assessments but these were old or from people's previous placements. Care plans also included information transferred from the person's previous service, however it was unclear if the information was still accurate and up to date since moving as records were not dated.

People we spoke with were able to tell us that they felt safe and supported at Chipstead Lake. A relative told us, “I’d just add that overall I am pleased with the way (Name) is cared for and looked after, with only a few issues that blighted his care, usually the care is there, I haven’t got any issues with it. I’m pleased he has a voice. If he was treated badly he would tell me or his sisters.” Another relative told us, “I leave here feeling happy as I know he is safe and well cared for so I can relax.”

The registered manager told us there were no current open safeguarding alerts for the service. However, we were not assured that all incidents which may have required a referral to local authority safeguarding teams had been considered. We were told about incidents which would have required a referral to safeguarding but this had not been completed. Staff were able to recognise the different signs of abuse and what action they would take to raise appropriately to keep people safe from harm. They said “The team leader on shift is the first line of defence, then the deputy manager and registered manager. If nothing got cleared with them, I would go to the area manager, then head office.” and “I would report to the team leader and if no action taken, report to deputy manager/ registered manager, if not actioned, I would report to CQC.”

We observed people receiving safe care and support from staff.

The provider had a policy on safeguarding which was available to all staff which detailed the different types of abuse and what to do when concerned about something. The policy states that the registered manager will lead on actions and raise to local authority, then to raise to CQC, this had not been done. We could not find records of safeguarding alerts being raised appropriately. The evidence we reviewed suggested that the last safeguarding alert raised was in 2023. We are aware of incidents which should have been raised to the local authority but had not been done by the current or the previous registered manager.

People and relatives expressed concern about their experience of staff managing risk. One relative told us, “My son always says some people do not understand people with a disability. He is amenable, he lost his speech for a while, but he’s ok now. I think they thought he was putting it on.” Also, “Some carers are not understanding of his disability, the physiotherapist trains them in hoisting, some of them say ‘I don’t do it like that’, he says to them ‘That they should do it’. I tell him to complain to the management team and it will get sorted, they can’t watch every carer, he has got diagrams in his room, but it doesn’t always happen.”

The registered manager told us that all risk assessments that require updating and reviewing would be completed as soon as possible. They were aware that some were out of date and would work towards immediately getting them up to date. Staff told us they know people well and know what risks they may be exposed to. Risk assessments had been completed but the assurances that they were current and up to date was not there. Staff told us, the care plans and risk assessments were too large and they were not sure how much guidance they gave. “They are too big for member of staffs, 500 pages, if we are full there are 24 residents, it’s a lot to take in. Streamlining is needed, a snapshot of what they need, there’s a lot of detail and it’s duplicated. there is a new form for everything why are we spending hours doing that when we should be looking after them, it’s frustrating.” Staff told us, “Some of them could be more detailed, unfortunately we have had 4 managers in the last 4 years, everyone has their input, and it doesn’t always get fulfilled." Some staff reported that changes to the care plans and risk assessments were planned, and they would be welcomed, “The registered manager wants to put communication and fluid charts in people’s rooms which I feel would be brilliant.”

We observed people being treated well and supported to manage the risks.

The service did not have effective systems in place to make sure risk assessments were accurate and up to date. This had been identified by the provider shortly before this assessment. Some individual risk assessments were in place. However, none of these were up to date, they had been completed over 12 months ago and no reviews had been undertaken. Some people who were at risk of poor nutritional and fluid intake had been placed on charts to record their intake. People’s daily records were not always fully completed by staff each day. Daily recording of food and fluids where it was required was poor and we could not be assured as accurate, this had not been identified. Action had not been taken to check if people were unwell. Staff had completed assessments of risks to people's health using recognised tools such as Waterlow, to assess skin integrity. When these assessments had indicated people were at high risk, and required regular review, this had not been completed. This placed people at risk of not receiving care which was effective and reduced risk. People’s moving and handling risk assessments were current and up to date, these had been completed by the in-house physiotherapist. These plans were detailed, giving the staff information on people’s ability, what they require support and if they require support with equipment, details on how the staff are to use it are included.

People we spoke with told us they do not have any concerns with the environment. The service had installed tactile boards such as a model bed to signify a bedroom and a spoon mounted at the dining room. This enabled people who were sight impaired to identify where they are.

Staff told us that actions being or in process of being taken have had a positive impact on them and their morale as they can see things happening. “Yes, the registered manager is planning on having the place redecorated which will help the residents and it’s changed how staff feel.”

We observed people coming and going as they wished. They were able to freely move around the building and people who used their own wheelchairs had an accessible space to use. People had door entry fobs which allowed them access through the key code secured main doors. Corridors were wide and people interacted with each other as they navigated the service.

There was a plan in place the registered manager had completed with the provider to make improvements to the environment.

Relatives told us, they supported staff to understand their loved ones needs and preferences, especially new staff. However, one person told us they did not always receive support as they preferred, “I want my teeth cleaned every day; some staff do not do this. Sometimes I am put to bed at 7pm which is too early, 8pm is better. Some staff talk about me to each other, they do not realise I can understand.”

Staff told us there were enough suitably qualified staff. Many staff had worked at Chipstead Lake for several years. Staff told us, “There has been a high staff turnover which has been difficult, but the last few weeks it has got better and seems to be more stable again, so now only working with permanent staff, even though some are new”. The registered manager told us that the service is nearly fully staffed with support workers, “We had low staff levels, now we are pretty much fully staffed and only have vacancies of 2 or 3 support worker roles and 1 domestic role.” Staff told us, training was not always helpful. Comments included, “The training isn’t great, a lot of it is on computer” and “Training, personally, I pass the tests, but I can’t remember what I have learnt”.

Staff had good relationships with people and knew them well. There were enough staff to support people.

Staff had been recruited safely. Recruitment records contained all the required information and checks on staff suitability to work with people. Staff were allocated by team leaders, who made sure the same staff did not always work together to reduce the risk of a closed culture.

People told us they were happy with the cleanliness of the service.

The registered manager told us the cleanliness of the building was a top priority when they joined the service. They said that the level of cleanliness had not been up to their standard and immediately took steps to improve this. They had employed agency staff to support in the domestic team and hired equipment to clean the carpets.

The premises appeared clean during our on site assessment visit.

Although the service and people's rooms were clean, there were no current cleaning schedules in place. There was no system to make sure all areas were cleaned including the frequency of cleaning required. For example, some areas may need to be cleaned daily and other areas weekly or less frequently.

One person received their medicines received their medicines covertly, the authorisation had been agreed by the person's previous GP not the GP who covers Chipstead Lake. Staff had not checked with the GP to make sure covert medicine administration was still appropriate for the person.

Staff told us they used an electronic system to support medicines management, and this worked well. The staff who administered people’s medicines were able to describe how they made sure safe management was followed to reduce risks. Staff told us the registered manager had decided a bigger room was needed for the storage of medicines. They had started to plan this quickly, identifying a more appropriate space and this was in the process of being refurbished to meet regulations for medicine storage. Staff said they were pleased as they would have more storage and space.

People’s medicines were managed safely. However, people's medicines had not always been reviewed by their current GP. Staff had not attempted to retrieve documents about a person's medicine administration which were with their previous GP. Staff were giving medicines covertly but had no evidence to show how the decision had been made. There was a risk people were not receiving their medicines in the most appropriate way for them. The provider used an electronic system to record and support the administration of people’s medicines. When we completed a random count of medicines, we found 2 medicines did not tally with the records. Staff checked this and found this was a recording error by the electronic system and put this right immediately. Protocols were in place for the safe administration of medicines prescribed as and when necessary, such as painkillers.