Chargrove Lawn

Support was delivered across 2 floors. There were communal gardens around the building that people could access.

Who the service is for

The service supports older people including people living with dementia.

Key findings

We carried out this assessment from 28 July to 14 August 2026. This service was previously rated as good. We carried out this assessment to confirm whether the rating of good remains accurate. This report does not provide detailed information on areas where we found practice continues to meet a good standard. Instead, our findings focus on any areas where the service needs to improve or where we found exceptional practice.

We assessed whether the service was operating in line with the principles of the MCA and how DoLS were managed. People can only be deprived of their liberty to receive care and treatment where there is appropriate legal authority. In care home settings, this is usually authorised through the Deprivation of Liberty Safeguards (DoLS), which form part of the Mental Capacity Act 2005 (MCA). We found that staff and management worked within the MCA. DoLS authorisations were appropriately applied for and overseen. People were not subject to unlawful or excessive restrictions they had choice, control and freedom over their lives. The provider had systems to record DoLS applications and associated conditions.

Safeguarding concerns were promptly and appropriately shared with relevant agencies. Staff received role-specific safeguarding training and were equipped to identify individuals at risk. They understood the systems, processes and procedures in place to protect people from abuse and felt confident raising any concerns.

A safeguarding log was in place, which documented safeguarding concerns, actions and outcomes, and which other external agencies had been notified. There was a policy in place reflecting partnerships with external agencies and the local authority safeguarding teams. At the time of the assessment, the provider’s policy was under review by head office to ensure it remained up to date and reflective of best practice

Systems were in place to ensure accidents and incidents were reported, investigated and any areas of learning or improvement were identified and shared with staff. Information was also recorded and reviewed on the providers electronic system, with outcomes monitored. Staff confirmed they were able to discuss all accidents and incidents to learn and improve future practice.

Care plans included person-centred information about people’s nutrition and hydration needs, allergies and intolerances, including details of any enhanced monitoring, risks or related health conditions. Peoples care and support was provided in line with their care plan. Individual risks were well managed. Risk assessments were personalised and clearly detailed, including the actions needed to mitigate risks. Staff demonstrated they knew people well. Staff could identify triggers for people which may produce an emotional or behavioural response. Regular reviews of care plans were carried out to ensure they remained accurate and reflective of people’s current needs.

Information about people’s health conditions was accurately recorded, which enabled staff to monitor any deteriorations from a person’s usual presentation. For example, we saw one person’s care plan clearly recorded information about their diabetes, with clear protocols for staff to follow. This was accompanied by a risk assessment to guide staff to monitor and support the person effectively. One family member told us “Staff picked up on my [relative] when they were showing signs of depression and consulted the GP. Medication was prescribed”.

There was a clear assessment process completed prior to people moving into the service. This included a holistic assessment of their needs, preferences and aspirations which ensured staff fully understood people’s individual support requirements.

People were supported by a consistent staff team who knew people well and could respond effectively to any changes in need. Staff were clear about the actions they would take if they found people unwell. They communicated well with people and their relatives to promote positive outcomes and refer people to health and social care services as needed.

There were sufficient staff on duty to meet people’s needs. A dependency tool was used to provide a structured method to assess the care needs of people and ensure their needs were met by the right number of staff with the right skills at the right time. One person said, “I feel there's enough staff to support everyone”. One family member said, “Always staff [at the home], visit after work and staff about, don’t hear call bells going unanswered”.

Recruitment checks had been completed for all newly appointed staff prior to commencing in their roles.

Staff had completed mandatory and role-specific training. However, a review of the training records identified that some training had lapsed or was approaching its renewal date. We also found that staff had not received training in supporting autistic people and people with a learning disability. This did not have any impact on people using the service. We shared this with the provider who told us systems and processes were being strengthened to improve oversight of training compliance. This would ensure that mandatory and specialist training was completed and renewed in a timely manner, reducing the risk of training expiring in the future. One staff member told us, “Training is good, the system can sometimes be a little frustrating”.

Staff received regular supervision. One staff member told us, “I have supervision and I have medicines competencies and care observations”. Another staff member said, “Supervisions are 2 monthly and they do help”.

Medicines were managed safely. Staff responsible for administering medicines had received appropriate training and had their competencies assessed. People had detailed medicines care plans in place, which provided clear guidance to support the safe management and administration of their medicines. Staff followed appropriate protocols when administering medicines prescribed on an ‘as required’ (PRN) basis. One family member said, “Management went through medication and dosage changes, happy with how they manage medication, approach me if anything needs changing”. Another commented, “No concerns at all, [relative] was on an awful lot of medication, no issues at all and can discuss it with them and they have doctor in, happy”.

Weekly and monthly medicines audits were completed to ensure medicines were administered and managed safely in line with people’s prescriptions and the provider’s policies. Policies and procedures were in place to guide staff in the safe administration of medicines.

Consent to care and support was routinely obtained and recorded when delivering care to people. Where people lacked capacity to make specific decisions, staff followed the principles of the Mental Capacity Act 2005 (MCA). This ensured that care was delivered lawfully and in line with people’s wishes. Staff had received training on consent and mental capacity so they could apply this knowledge in practice. A log was in place to monitor and provide oversight of people who had been assessed under the mental capacity act and deemed to lack capacity.

Staff told us that leaders were visible, approachable and supportive. They described a positive management culture where leaders were accessible and demonstrated a genuine commitment to staff wellbeing. Leaders showed a clear understanding of the service, including the challenges associated with delivering safe, effective and high-quality care.

Leaders demonstrated they were actively involved in the day-to-day operation of the service and demonstrated a strong commitment to providing person-centred care that met people's individual needs and preferences. Staff spoke positively about the support they received and felt leadership promoted a culture focused on continuous improvement and good outcomes for people using the service. One staff member said, “I think our management is great. I do feel like a valued, worthy member of the team, and we are a superb team at that”.

The service was located within an older building and parts of the environment were in need of redecoration. Feedback from relatives reflected this, with one family member commenting, “The home needs a good paint in the corridors.” The registered manager acknowledged this and told us there was a plan in place to improve the internal environment.