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CQC report explained · a nursing home

What the CQC found at Charlotte James Nursing Home

Goodpublished 22 February 2023, 3 years ago

Rated Good: inspectors found the home performing well and meeting their expectations.

The five questions inspectors ask
Safe?
Good
Inspectors found that risks were assessed and managed, medicines were handled safely, and there were enough staff who had been safely recruited. Infection prevention systems were also in place.
Effective?
Good
People's needs and choices were assessed, and staff had training to support them. The home supported eating and drinking, access to health services and lawful consent arrangements.
Caring?
Good
Staff treated people with kindness, dignity and respect. People were involved in decisions about their care and encouraged to remain independent.
Responsive?
Good
Care was tailored to people's needs and preferences. People were supported with communication, relationships, activities, complaints and end-of-life care.
Well-led?
Good
Inspectors found positive leadership, clear roles and an open culture. The provider used audits, feedback and incident reviews to improve care.
The latest report, explained

What inspectors found, February 2023

Rated Good; inspectors found safe, kind and personalised care, with some records and end-of-life planning still being developed.

This was an unannounced inspection on 19 and 24 January 2023. Inspectors spoke with people, a relative and staff, observed care, and checked care, medicine, recruitment and management records.

The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough safely recruited staff, safe medicines, managed risks, good infection control and a clean, well-maintained environment.

People were treated with kindness and respect. Their care was tailored to their preferences, and staff supported food, communication, activities, family contact and access to health services. The home was still improving its electronic care records and adding more detail to some end-of-life plans.

What inspectors praised
  • Safe staffing and medicines

    Inspectors found enough staff to meet people's needs, with appropriate recruitment checks. Medicines were stored, given and recorded safely.

    “People were supported by enough staff who were safely recruited to work at the home.” from the report
  • Kind and respectful care

    Staff spent time with people, respected their choices and promoted privacy, dignity and independence.

    “Staff were passionate about ensuring people were treated well and they respected their equality and diversity.” from the report
  • Personalised support

    Care plans reflected people's preferences, and staff knew how people wanted their care delivered.

    “People's care was tailored to their needs and preferences.” from the report
  • Learning from incidents

    The manager reviewed accidents and incidents, looked for patterns and changed staffing arrangements when a pattern of falls was identified.

    “Lessons learnt were documented under each recorded incident to help reduce reoccurrence.” from the report
  • Activities and communication

    People had different ways to communicate and a range of activities, including family contact, games, visitors and sensory activities.

    “People had choices of activities to participate in during the day.” from the report
What inspectors were concerned about
  • Electronic care records

    minor

    The home was moving care records from paper to electronic systems. Inspectors noted that the electronic system could produce generic statements, so the home used extra reviews to keep information person-centred.

    “The provider was in the process of transferring people's care records from paper to electronic.” from the report
  • Further end-of-life details

    minor

    Emergency care information was recorded, but the manager was still adding more specific wishes, such as music requests.

    “The registered manager was in the process of adding further specific details including music requests for example.” from the report
Questions to ask them, based on this report
  1. 01How do you check that electronic care records remain accurate and personalised while information is transferred from paper?
  2. 02What extra end-of-life details are now recorded, including personal wishes such as music requests?
  3. 03How do you make sure staffing levels remain sufficient for each person's individual needs?
  4. 04How are falls, accidents and incidents reviewed, and what changes have been made as a result?
  5. 05What activities and communication support would be available for my relative's specific interests and needs?

This was an unannounced first comprehensive inspection since registration; CQC looked at all five ratings, the premises and the care provided. This explanation was written from the published report of 22 February 2023 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.

The story over the years

Every inspection of Charlotte James Nursing Home

4 rated inspections over 8 years: the service has improved, from Requires improvement to Good.

  1. February 2023Goodcurrent ratingstayed Good
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good

    Read what inspectors found at Charlotte James Nursing Home →

  2. May 2017Goodup from Requires improvement
    Safe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
  3. May 2016Requires improvementstayed Requires improvement
    Safe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
  4. August 2015Requires improvement
    Safe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
  5. December 2019

    Registered with the Care Quality Commission on 16 December 2019.

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.

Next steps

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