Charnwood Oaks Nursing Home

The inspection identified serious concerns about people’s safety and day-to-day experience. We observed multiple instances where people were distressed or calling out for help and staff did not respond promptly, and we saw people in undignified situations where privacy was not respected. Risk management was not effective, including Positive Behaviour Support (PBS) plans and incident analysis (ABC charts) lacking detail, gaps in clinical oversight and recording (such as pressure care and repositioning evidence), and weaknesses in infection prevention and control, including cleanliness of mattresses and equipment and poor communication during an infection outbreak.

Leadership and governance systems were not robust enough to identify and address risks, and learning was not sustained, including repeated Regulation 12 Safe care and treatment concerns across multiple inspections. There was evidence of a breakdown in communication between care staff and senior leaders, and leaders did not demonstrate effective oversight of people’s needs and clinical risks, including the absence of a clinical risk register.

As a result, the provider is in breach of 3 legal regulations relating to dignity and respect, safe care and treatment and good governance.

We did observe staff to be friendly and welcoming to inspectors, recruitment processes were safe and well organised, and there were pockets of good practice such as secure controlled drugs storage, clear labelling of insulin pens, appropriate escalation to Speech and Language Therapy after choking incidents, and meeting DoLS conditions where these applied. Relatives often spoke positively about day staff and described regular visits from health professionals, limited hospital admissions for many people, and that end‑of‑life wishes had been discussed and recorded for some people. There were also some person-centred touches, such as supporting wishes and goals and thoughtful bereavement gestures for families.

While the service had some strengths and committed staff, urgent and sustained improvement was required to ensure people were treated with dignity, received safe care, and that leaders’ oversight systems would reliably drive improvements.

This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.