Charnwood Care Home

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

We identified a breach of legal regulations. Peoples needs and rights were not well supported. National risk assessment tools were not used effectively to produce good outcomes for people. Care plans did not always provide clear guidance to staff. Staff did not keep clear records on what care was provided to people, we were therefore not assured that people received care effectively and in line with their needs. We found staff did not always work effectively together, or with external health and social care professionals. Staff had received some training on the Mental Capacity Act. However, they did not have good knowledge. Documentation had not always been completed to assess what decisions a person could make, and how staff could support them in their best interests and least restrictive way.

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.

People told us that they had not been asked questions about their care needs, or how best they could be supported. This meant staff did not involve people when assessing their needs.

The new manager had found there was a historic lack of pre-admission assessments. This meant people’s needs had not been thoroughly assessed before they came to live at Charnwood Care Home. They intended to make improvements on this when new people came to live at Charnwood Care Home.

We saw staff had not gathered clear information on people’s care needs, before they came to live at Charnwood care home. This meant staff did not have clear guidance on how to support people. After people arrived, care plan documentation was also not detailed or clear enough to guide staff.

People did not always receive care that was in line with evidenced based practice. This is because national risk assessment tools were not use effectively.

Staff told us care plans were not regularly updated to reflect people’s care needs. They said this could impact their understanding of the care required for a person.

People’s care needs were not clearly assessed. For example, a risk assessment designed by the care home identified a person as having a ‘very high’ risk of malnutrition. However, the service had also used a national malnutrition scoring tool. This document identified the person was not at risk of malnutrition. This contradictory information across these documents, meant staff would not have clear understanding of the person’s risk of weight loss. This could impact the care provided.

People and relatives felt that the staff team did not always work well together. A relative said, “New staff are not up to speed. Regular carers know what they were doing.”

Staff told us that the staff team were not always effective. Staff explained that when tasks were assigned to certain staff, they found these tasks were not effectively done. This meant that other staff needed to check their work and complete these tasks again. Staff felt that there was good communication with external health care teams. Staff were able to explain which health professionals supported which people. However, this was not always clearly documented so all staff would be aware.

We did not receive feedback from external partners.

Staff did not always receive a clear handover of information. After our first assessment day, we reported concerns to the management team. When we returned on our second assessment day, staff had received some written messages from the management team. However, did not understand the meaning of these messages.

People told us that staff supported them well. However, we were not assured that people were supported to live healthy lives. This is because records kept by staff suggested people were not drinking enough, were not eating suitable food and were not being repositioned regularly to maintain their health.

Staff explained that not all staff were proactive in offering people care. They explained that if a person was unclean or unwell, then a second staff member would sometimes be the one to recognise and respond.

Records kept by staff, suggested people did not always live healthy lives. For example, a person required support to reposition every 2 hours. This was to give pressure relief and prevent their skin becoming damaged. However, records kept by staff suggested the person had been the same position for up to 6 hours. We explained this risk to the management team. The management team felt the person was likely to have moved to other positions, but staff had failed to record this. When we returned on a second day, records continued to suggest the person had been sat in the same position for long periods. We were therefore not assured that the person was being repositioned as often as required.

People did not always experience good outcomes. This is because their needs were not always clearly recorded and monitored. For example, we saw a person was repeatedly agitated during the assessment. The person’s care plan did not give staff guidance on what could trigger this behaviour, or how staff should effectively respond to reassure the person. We saw staff did not respond effectively to the person’s agitation. Staff also did not document this person’s distress. This could make it difficult to monitor themes/triggers and ensure improved outcomes for the person

Staff explained that they did not always have time to read care plans. This could impact their understanding of people’s current needs.

Staff did not keep clear records on people’s health and social needs. For example, one person had pressure related skin damage. The staff had recorded this injury as more minor than it actually was. By not clearly recording the seriousness of the wound, it would make it difficult to monitor if the wound became better or worse. This could impact treatment decisions.

People felt staff asked their permission before completing care tasks. For those people who were not able to give permission (due to confusion) we saw staff approached them in a kind way and explained to the person how they would support in the person’s best interests. Staff explained that this was not always the case. One staff member said, “the staff tend to just go in without knocking and just start undressing them, not even explaining what they are doing.”

Staff had received some training on the Mental Capacity Act. However, when we asked them questions their knowledge was poor. Some people at the service were subject to a Deprivation of Liberty Safeguard (DoLs), this is where the person cannot make decisions about their care and treatment. So restrictive care arrangements are legally authorised in the person’s best interest. The care staff had a poor knowledge of how DoLs would impact their care of a person and what they should do if the person did not consent to their care.

Mental capacity assessments had not always been completed. This meant restrictions were in place without assessing people’s ability to make their own decisions. For example, a person would regularly decline personal care support. Staff would continue to offer support with bathing. However, no mental capacity assessment had been completed to assess if the person was able to make their own choices to decline this care.