CQC report explained · a nursing home
What the CQC found at Chapel Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were assured about most infection-control measures, but were only somewhat assured that people were admitted safely. They also found vacancies and informal arrangements for covering staffing shortfalls.
- Effective?
- Good
- This targeted inspection did not assess or rate this question.
- Caring?
- Good
- This targeted inspection did not assess or rate this question.
- Responsive?
- Good
- This targeted inspection did not assess or rate this question.
- Well-led?
- Good
- This targeted inspection did not assess or rate this question.
What inspectors found, March 2022
Chapel Lodge had good infection-control arrangements but staffing gaps; the service was inspected but not rated.
This was a short, announced, targeted inspection on 8 February 2022. Inspectors looked at infection prevention and control, visiting arrangements and staffing pressures linked to COVID-19. They spoke with three staff members and two residents.
Inspectors were assured about most infection-control arrangements. These included cleaning, PPE, testing, visits, outbreak management and vaccination requirements. They found a visiting plan that considered one resident's health and wishes.
The service was recruiting for several vacancies, including cleaning and bank staff. Inspectors said cover arrangements were informal. They were only somewhat assured that people were being admitted safely.
The service was inspected but not rated. This means the inspection did not produce a new overall quality rating.
Infection-control checks
The home used regular checklists covering frequently touched areas during previous outbreaks. These checks were intended to reduce the spread of viruses.
“This outlined all pre-shift, mid-morning, post-lunch and mid-afternoon areas for cleaning staff to inspect and ensure were clean to minimise any viral spread.” from the report
Support for visiting
Inspectors found a visiting plan that considered a resident's physical and mental health and their ability to understand decisions. Safety measures were put in place for a family visit.
“Staff had supported them to spend Christmas day at their daughter's house and put IPC/PPE safety measures in place.” from the report
Wider infection safeguards
Inspectors were assured about testing, PPE, visiting arrangements, outbreak management and the home's infection-control policy.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Vacancies and informal cover
needs fixingThe home was recruiting for several roles. Inspectors said the arrangements for other staff to cover gaps were informal.
“Manager's solutions to cover any shortfalls in these areas was quite informal whereby other staff would help cover duties in the interim.” from the report
Safe admissions
needs fixingInspectors were not fully assured that people were being admitted safely. The report does not give further detail about the issue.
“We were somewhat assured that the provider was admitting people safely to the service.” from the report
- 01Which vacancies were still open after the inspection, and how are cleaning, activities and bank-staff gaps being covered now?
- 02How do you make sure informal staff cover does not reduce people's care, activities or cleaning standards?
- 03What checks are completed before a new resident is admitted, and what was meant by inspectors being only somewhat assured about safe admissions?
- 04How do you keep visiting arrangements safe while making sure each resident's wishes and individual health needs are considered?
- 05What are the current arrangements for testing, PPE and managing an infection outbreak?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19-related staffing pressures; it did not rate the other four questions. This explanation was written from the published report of 1 March 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, June 2019
Rated Good and out of Special Measures; inspectors found safe, kind and personalised care after major improvements.
This was an unannounced inspection on the first day and an announced visit on the second day. The inspector spoke with people living in the home, relatives, staff, managers and healthcare professionals. They also observed care and checked care records, staff files and management information.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found that medicines, risk management, care plans, staffing, training and cleanliness had improved. People were treated with kindness and respect, and their care was tailored to their needs and preferences.
The home had been rated Inadequate and placed in Special Measures at the previous inspection in August 2018. Inspectors found that the required improvements had been made, including stronger checks by managers and more complete care records. The home was therefore no longer rated Inadequate and was taken out of Special Measures.
Safer medicines
Medicines systems had improved substantially. Inspectors found that medicines were organised, given at the right time and checked effectively.
“People's medicines were well managed. Medicines systems were well organised, and people were receiving their medicines when they should.” from the report
Personalised care
Care plans reflected people's needs, wishes and preferences. Staff shared changes through handovers and team meetings.
“People received person centred care that was tailored to their individual needs and preferences.” from the report
Kind and respectful staff
People and relatives described staff as caring and respectful. Staff supported people's dignity, choices and independence.
“Staff were caring and compassionate with the people they supported and their families.” from the report
Stronger management checks
The provider introduced more thorough audits and daily safety huddles. Senior managers also visited regularly and checked progress.
“The provider had improved the systems and processes to assess, monitor and improve the quality and safety of the service to make sure they were effective.” from the report
Manager registration was still being processed
minorThe new manager had applied to register with CQC, but the registration process was not complete during the inspection.
“The new manager was completing the CQC registration process.” from the report
Staff could be busy at weekends
minorStaffing levels were judged sufficient, but one relative said staff were sometimes very busy, especially at weekends.
“One relative said the staff were sometimes very busy, especially at weekends.” from the report
- 01Has the manager's CQC registration now been completed, and who is legally responsible for the home today?
- 02How do you make sure there are enough staff at weekends and during particularly busy periods?
- 03How are the daily safety huddles and regular audits used to identify and fix problems now?
- 04How often are care plans and risk assessments reviewed when a person's needs change?
- 05How do you check that medicines, including patches and controlled drugs, continue to be recorded and given safely?
This was a planned comprehensive inspection covering all five key questions, with Safe, Responsive and Well-led improving to Good and Effective and Caring remaining Good. This explanation was written from the published report of 12 June 2019 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 Chapel Lodge
4 rated inspections over 3 years: the service has improved, from Requires improvement to Good.
- March 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- June 2019Goodup from InadequateSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2018Inadequatedown from Requires improvementSafe: InadequateEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Inadequate
- February 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- October 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- October 2011
Registered with the Care Quality Commission on 5 October 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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