CQC report explained · a nursing home
What the CQC found at Charlton Court
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- Risk assessments were not always followed in practice. Controlled medicine records were inconsistent, some safeguarding procedures were not followed, and PPE and hand hygiene guidance was not always followed.
- Effective?
- Good
- This key question was not inspected during this visit. The previous rating was carried forward for the overall rating.
- Caring?
- Good
- This key question was not inspected during this visit. The previous rating was carried forward for the overall rating.
- Responsive?
- Good
- This key question was not inspected during this visit. The previous rating was carried forward for the overall rating.
- Well-led?
- Good
- The new manager had identified governance problems and started an action plan. Some audits and improvement records were not yet complete, but the service was still rated Good for leadership.
What inspectors found, July 2022
Charlton Court is rated Good overall, but Safe was Requires Improvement because risk instructions and some safety records were not always followed.
This was an unannounced inspection over two days. Inspectors observed care and mealtimes, spoke with people, relatives, staff and a healthcare professional, and checked care plans, risk assessments and medicine records.
The overall rating stayed Good, but Safe fell from Good to Requires Improvement. Inspectors found enough staff, a clean and well-maintained home, and people who said they felt safe. However, staff did not always follow risk assessment instructions, safeguarding procedures or infection control guidance.
Medicines were generally managed safely, but records for some controlled medicines were inconsistent. The new manager had identified problems and started an action plan, although some audits and improvement records were incomplete. Well-led remained Good.
The other three key questions were not inspected during this visit. Their previous ratings were carried forward when calculating the overall rating.
Enough staff
Inspectors found enough staff to meet people's needs. People were helped promptly when they asked for assistance.
“There were enough staff on duty to provide high-quality care to people.” from the report
People felt safe
People and relatives told inspectors they felt safe using the home.
“People felt safe and their relatives confirmed this.” from the report
Clean and maintained
The home was clean, tidy and well maintained. Environmental and equipment checks were also being carried out.
“The home was clean and tidy and well-maintained.” from the report
Kind staff relationships
People spoke positively about staff attitudes and how staff treated them.
“The staff are like family. I've only got to ask and its done.” from the report
Risk instructions not always followed
seriousCare risk assessments were in place, but staff did not always follow them. Inspectors found unsafe items left where one person could reach them, although the manager acted immediately.
“Risk assessments related to people's care and support were in place but were not always followed in practice by staff.” from the report
Safeguarding procedures
seriousStaff did not always follow safeguarding procedures. Safeguarding matters were being investigated by the provider and local authority at the time of inspection.
“Safeguarding policies and procedures were in place, but these were not always followed in practice by staff.” from the report
Controlled medicine records
needs fixingRecords for some 'when required' controlled medicines were not consistent. Protocols were not always completed so staff could see what guidance to follow.
“Record keeping of 'when required' controlled medicines were not always consistent.” from the report
Infection control practice
needs fixingThe home had infection control arrangements, but staff did not always follow guidance on protective equipment and hand hygiene. The manager took immediate action when this was raised.
“Government guidance relating to safe working practices including the use of PPE, and hand hygiene was not always followed by staff.” from the report
Incomplete audits
needs fixingSome audits were not fully completed, and the actions needed to improve the service were not always recorded.
“Some audits had not been fully completed, and the actions required to deliver service improvements had not been recorded.” from the report
- 01How do you now make sure staff follow each person's risk assessment, including instructions about unsafe items?
- 02What has changed in the recording and checking of 'when required' controlled medicines?
- 03What was learned from the safeguarding investigation, and what action has been taken?
- 04How do you check that staff consistently follow PPE and hand hygiene guidance?
- 05Which actions from the manager's plan and incomplete audits have now been finished?
This was a focused inspection of Safe and Well-led, including infection prevention and control; Effective, Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 16 July 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, February 2021
Inspected but not rated; inspectors were assured about infection prevention and control measures.
The inspection was an announced, targeted visit on 3 February 2021. It focused on infection prevention and control because the home had a COVID-19 outbreak.
Inspectors found good practice for visitors, including temperature checks, questions about infection risks, lateral flow testing, personal protective equipment and handwashing facilities. They were assured that the home was managing infection risks, including admissions, shielding, social distancing, testing, hygiene and outbreaks.
The home supported video calls and visits in line with national guidance. Staff movement between floors was reduced, while staff worked flexibly to meet people's needs.
This was not a full inspection and no overall quality rating was given. The Safe question was marked inspected but not rated, and the other four questions were not assessed in this report.
Visitor safety checks
Visitors had temperature checks and were asked relevant questions before entering. The home also had personal protective equipment and handwashing facilities available.
“All visitors had to undergo a temperature check and answer a range of relevant questions before entry.” from the report
Family contact
The home supported video calls and visits in line with national guidance. It also used protective screens to help families keep in contact.
“The service had facilitated video calls and visits in line with national guidance.” from the report
Testing before entry
Visitors and contractors were tested with lateral flow devices before accessing the home.
“Lateral Flow Test devices were used to ensure visitors and contractors returned a negative test before accessing the service.” from the report
Reducing infection spread
Movement between floors was reduced to lower infection risks. Staff worked flexibly during the outbreak to meet people's needs.
“Movement of staff and people between floors was minimised to reduce the risk of spreading infection” from the report
Inspectors raised no specific concerns in this report.
- 01Are visitors and contractors still tested before entering the home?
- 02How are visiting arrangements managed now, including video calls and visits with protective screens?
- 03How does the home currently manage infection outbreaks and admissions?
- 04How are staff movements between floors managed when there is an infection risk?
- 05Can you show us the latest ratings or inspection information for caring, effective, responsive and well-led care?
This was a targeted inspection of infection prevention and control under the Safe question; it did not provide a full rating or assess the other four questions. This explanation was written from the published report of 20 February 2021 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 Charlton Court
4 rated inspections over 7 years: the service has held its Good rating throughout.
- July 2022Goodcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2021Inspected but not ratedSafe: Inspected but not rated
- February 2020Goodup from Requires improvementSafe: GoodWell-led: Good
- June 2017Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- April 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2014
Report published without a new overall rating.
- March 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- November 2011
Registered with the Care Quality Commission on 1 November 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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