What the CQC found at HF Trust Chestnuts

Inspectors saw kind and compassionate care from permanent and agency staff. People generally spoke positively about staff.

“We observed kind and compassionate care being delivered by both permanent staff and agency staff.” from the report

People were generally supported to have choice and control and to do things for themselves. Staff used the least restrictive approach possible.

“People were generally supported to have choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests” from the report

Trained staff administered medicines and understood people’s needs. The home supported health appointments and medicine reviews.

“Staff supported people with their medicines in a way that promoted their independence and achieved the best possible health outcomes.” from the report

People helped develop their support plans, chose food and personalised their rooms. Staff supported people with daily tasks and activities.

“People proudly showed us their rooms, comments included, "You can see, I am very keen on trains" and "My family" indicating photographs.” from the report

People said they did not feel safe, and some had been hit, punched or pushed over by people they lived with. There had been 20 incidents where harm occurred since February 2022.

“People had experienced physical and emotional abuse from others they lived with over prolonged periods of time.” from the report

Inspectors found 48 incident reports that lacked detail, were incomplete or contained incorrect information. Lessons were not effectively shared or used to reduce the risk of harm happening again.

“We found no evidence the incidents were formally reviewed or changes made to people's support plan to reduce the risk of re occurrence apart from adding more staff to provide some 1:1 support.” from the report

The specialist positive behaviour support team had not completed a robust assessment or provided detailed guidance for staff. Interim guidance and further support were put in place after the inspection.

“The provider had failed to ensure managers and staff had all the training and guidance they needed to support people appropriately when they were upset or anxious.” from the report

Some support plans were not up to date, staff knowledge of positive behaviour support was inconsistent, and training completion was generally below the provider’s expected level.

“People's needs were not always adequately assessed and support plans were not always kept up to date with most recent guidance for staff” from the report

As-required medicine protocols were not always available, and one person did not have an epilepsy bathing risk assessment until inspectors raised it. These issues were addressed during or immediately after the inspection.

“People did not always receive their medicines in accordance with the prescriber's instructions.” from the report