Charter House Resource Centre CIC received an overall rating of Requires Improvement at its first inspection, with breaches of Regulation 17 (governance) and Regulation 19 (recruitment) identified alongside a recommendation to strengthen medicines management. The service demonstrated genuine strengths in person-centred care, staff training, and safeguarding, with Good ratings across effective, caring, and responsive domains.
Concerns (5)
criticalGovernance: “The provider had failed to establish an effective quality monitoring system and had not always assessed risks to people's health and safety. (Regulation 17 (1) (2) b)).”
criticalStaff competency: “The provider had failed to operate a safe recruitment procedure. This was a breach of regulation 19 1(c) 3 (a)”
moderateRecord keeping: “the checks on people's personal and medicine records were informal and had not been recorded. It was therefore difficult to determine what action had been taken.”
moderateMedication management: “shortfalls in some aspects of the record keeping. This included a lack of guidance on the specific administration of certain medicines and medicines prescribed as necessary.”
moderateCare planning: “not all risks had been assessed in relation to skin integrity and the management of people's medicines.”
Strengths
· People felt comfortable and happy using the service; relatives described it as 'an exceptional service'.
· Sufficient staff were deployed with consistent care teams familiar with people's needs and preferences.
· Effective systems to organise care visits, minimising risk of late or missed calls.
· Staff trained in safeguarding, infection control, MCA, and equality and diversity.
· Registered manager promoted a person-centred culture and worked in partnership with health and social care professionals.
Quality-Statement breakdown (20)
safe: Staffing and recruitmentRequires improvement
safe: Using medicines safelyRequires improvement
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
effective: Supporting people to live healthier lives, access healthcare services and supportGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff support: induction, training, skills and experienceGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Engaging and involving people using the service, the public and staff; Working in partnership with others; Continuous learning and improving careGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candourGood