CQC report explained · a nursing home
What the CQC found at Chacombe Park
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, June 2022
Rated Good; inspectors found kind, effective care, but identified shortfalls in visiting guidance, response times and complaint handling.
This was an unannounced inspection carried out on 13 December 2021 and 18 January 2022. One inspector and an Expert by Experience spoke with people living in the home, relatives and staff. They also checked care records, recruitment files, training records, medicines records and other documents.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found that people were protected from abuse, received suitable care and medicines, and were treated with kindness, dignity and respect.
There were some problems. Visiting guidance was not always in line with government guidance, some identification documents for staff had expired, and some people waited for care after staff had checked they were safe. One relative was unsure who was handling a complaint. The visiting policy was changed after the inspection, and the identification issue was fixed on the day.
Kind and respectful care
People and relatives consistently described staff as kind and helpful. Staff knew people well and supported their dignity and independence.
“Relatives gave consistently positive feedback about the kind and caring way staff supported people.” from the report
Staff skills and support
Staff received induction, training and competency checks before working independently. They also worked with health professionals to support people's health.
“Staff received training and support that enabled them to carry out their role effectively.” from the report
Activities and community links
People could take part in daily indoor activities and community activities such as farm visits and pub lunches. This helped people maintain relationships and feel part of the local community.
“People were supported to take part in activities that promoted their well-being.” from the report
Improved leadership
The home had monitoring systems and support for the registered manager. Inspectors rated Well-led Good, improved from Requires Improvement at the previous inspection.
“At this inspection the rating has changed to good.” from the report
Visiting guidance
needs fixingThe provider's visiting policy was not always in line with government guidance and caused confusion for some relatives. The policy was changed after the inspection.
“The provider's policy was not always in line with government guidance and this was a concern for some relatives.” from the report
Some delays in care
needs fixingAlthough staff were seen responding to people, some people said they had to wait for care and support after staff had checked they were safe.
“They come quickly to check you are safe, but then I might have to wait a while.” from the report
Recruitment records
minorSome key identification documents for staff had become out of date and this had not been identified. The issue was corrected by the end of the inspection day.
“However, we found some key identification documents had become out of date and this had not been identified.” from the report
Complaint follow-up
needs fixingOne relative was not sure who was dealing with their complaint. Inspectors raised this with the registered manager.
“However, another relative had complained and was not sure who was dealing with the complaint; we fed this back to the registered manager.” from the report
- 01How quickly do staff respond when my relative needs care, and how do you monitor any delays?
- 02What is the current visiting policy, and how will you explain any changes to relatives?
- 03Who will handle my complaint, and how will I be kept informed about its progress?
- 04How do you make sure staff identification and other recruitment checks remain up to date?
- 05What improvements have been maintained since the Well-led rating changed from Requires Improvement to Good?
This unannounced inspection covered all five key questions and included infection prevention and control; it was prompted in part by concerns about visiting arrangements and management. This explanation was written from the published report of 15 June 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, January 2018
Chacombe Park is rated Good overall; inspectors found safe, kind and responsive care, but the home needed improvement in leadership.
This was an unannounced comprehensive inspection on 27 and 30 October 2017. One inspector spoke with people living in the home, visitors, staff and managers. They observed care and checked care records, medicines, recruitment, training, maintenance, complaints and quality checks.
The home was rated Good for safe, effective, caring and responsive care. Inspectors found enough trained staff, suitable care plans, safe medicines arrangements, timely healthcare and respectful support. People said they felt safe and enjoyed their meals.
The home was rated Requires Improvement for being well-led. There had been no registered manager in post for more than six months, although a new manager was registered on 20 November 2017. Inspectors also found some older notification records had not been completed to the expected standard.
Safe staffing
Inspectors found enough experienced and trained staff to meet people's needs safely. Recruitment checks were completed before staff started work.
“The provider had ensured that there were sufficient numbers of experienced and trained care staff on duty” from the report
Personalised care
Care plans described people's individual needs and preferences. Staff used this information to support people and manage risks.
“Care plans were individualised and risk assessments were updated as changes to people's dependencies occurred.” from the report
Kind and respectful support
Staff respected privacy, dignity and personal choices. People were supported without being rushed.
“People were supported to do things at their own pace.” from the report
Food and healthcare
People had enough to eat and drink, with varied choices and support where needed. Inspectors also found timely access to healthcare.
“People said they enjoyed their meals, and had enough to eat and drink.” from the report
Leadership continuity
needs fixingThere was no registered manager when inspectors visited, and the home had been without one for more than six months. A new manager was registered after the inspection.
“The service had been without a registered manager since 18 April 2017” from the report
Older records were incomplete
needs fixingA follow-up report about a 2016 safeguarding notification had not been completed. The new manager corrected this, but inspectors said stronger checks were needed to make sure improvements lasted.
“A follow-up report routinely requested by the Local Authority had never been completed.” from the report
Supervision for some bank staff
minorSome bank staff who worked infrequent shifts had not always received regular supervision. The manager was addressing this during the inspection.
“The registered manager had identified that some 'bank staff' that worked infrequent shifts had not always had regular supervision meetings.” from the report
- 01How has the new registered manager kept the improvements going since registration in November 2017?
- 02How many permanent nurses and care staff are now in place, and how often are agency staff used?
- 03How do you check that follow-up actions after safeguarding notifications are completed and recorded?
- 04How often do infrequent bank staff receive supervision and training?
- 05How do you make sure the activities information is accurate and reflects changes made on the day?
This was an unannounced comprehensive inspection covering all five CQC questions, with the home rated Good overall and Requires Improvement for well-led. This explanation was written from the published report of 12 January 2018 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Chacombe Park
3 rated inspections over 7 years: the service has held its Good rating throughout.
- June 2022Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- September 2011
Report published without a new overall rating.
- February 2011
Registered with the Care Quality Commission on 15 February 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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