Chipstead Lake - Care Home Physical Disabilities

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.

Staff understood how to support people to make decisions and people’s right to make informed decisions even if they are unwise. However, records did not follow best practice guidance, people’s capacity assessments were poor and best interest decisions were not recorded. Decisions made at people’s previous care home had not been reviewed or reapplied for as required. People’s needs had been assessed using nationally recognised tools. However, these assessments had not been reviewed when people had been identified as high risk, such as skin damage or weight loss. Some people required their food and fluid intake to be monitored. Records were not accurate, these records were used to make decisions about people’s care. There was a risk people would not receive appropriate care. People were supported to live as healthier lives as possible. Staff worked well with other healthcare professionals.

We observed people being treated with kindness and compassion, some people commented they did not feel this was always the case. Most people and relatives told us they were happy with the care they received. People told us they were supported to be independent and had choices about their daily lives. Care plans contained information about what people could do and reflected their preferences.

People had not always been supported to set and achieve goals. People’s records were not always accurate, reviewed or still relevant to them. However, the registered manager was aware people needed to be more involved in planning their care.

People, staff and health professionals were positive about the new registered manager and the changes they are making to improve the service. However, we found shortfalls in the monitoring of the quality of the service. There were shortfalls in people’s documentations which were not always accurate and had not been reviewed. There had not been a system in place to make sure incidents were used for learning and improvements. The management had limited contact with groups outside of the providers services, this limited their ability to improve and keep up to date relevant to their people’s needs.