CQC report explained · a nursing home
What the CQC found at Charnwood House Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Staff understood people's risks and medicines were managed safely. However, care and risk records were not always current or accurate, and records did not always clearly show the support people had received.
- Effective?
- Good
- People's needs and choices were assessed, staff had received additional training, and the home worked with health professionals. People had access to suitable food, fluids and healthcare support.
- Caring?
- Good
- People were treated with dignity and respect, supported to make choices and encouraged to remain independent where possible. Staff knew people's preferences and responded to calls for help.
- Responsive?
- Good
- Care was personalised and people and relatives were involved in reviews and decisions. People had access to activities, community trips and support to maintain relationships.
- Well-led?
- Requires improvement
- Leadership had improved and people, relatives and staff spoke positively about the management. However, audits did not always identify shortfalls or record clear actions and responsibilities to put things right.
What inspectors found, August 2023
Rated Requires Improvement and no longer in Special Measures; care was kind and responsive, but records and quality checks were not reliable enough.
This was an unannounced follow-up inspection on 18 and 19 July 2023. Two inspectors and an Expert by Experience spoke with people, relatives, staff and a professional. They reviewed six people's care records and other service records.
The home had improved since the previous inspection, which was rated Inadequate with six breaches. Inspectors found better medicines management, safeguarding, staff training, infection control, activities and the home environment. They rated Effective, Caring and Responsive as Good.
However, some care records did not accurately describe people's needs or the support provided. The home's audits did not always identify these problems or clearly record who should fix them. Safe and Well-led were rated Requires Improvement, and the overall rating was Requires Improvement.
The home is no longer in Special Measures because it was no longer rated Inadequate. CQC still required an action plan and said it would monitor progress and return to inspect again.
Improved safety systems
The home had improved its approach to safeguarding, incidents, medicines and environmental safety since the previous inspection. Inspectors found enough improvement for earlier breaches relating to safe care and safeguarding to end.
“Since our last inspection the registered manager and provider have implemented effective systems to protect people from avoidable harm.” from the report
Kind and respectful care
Staff understood people's needs and preferences and supported dignity, independence and personal choices. People and relatives spoke positively about the caring culture.
“People and their relatives spoke positively about the caring nature of care staff.” from the report
Personalised activities
People took part in activities suited to their interests and needs, including arts and crafts, reading, reminiscence and community trips. The home also planned to develop these activities further.
“We observed staff providing people with activities and engagement tailored to their needs, including arts and craft, ball games, reading and reminiscence.” from the report
Better staff support
Staff had received extra training and support in areas linked to the people living at the home. Staff and relatives said workers had the skills and support needed to provide care.
“Since our last inspection the registered manager and provider had supported staff to access appropriate training and support in relation to dementia, anxious behaviour and learning disabilities.” from the report
Good partnership working
The home worked with GPs, community nurses, speech and language therapists and other professionals. Inspectors received positive feedback about this work.
“The registered manager and staff worked with healthcare professionals to ensure people received effective care and support.” from the report
Care records were not always accurate
seriousSome records did not reflect people's current needs, including choking risks and changes in required support. Records also did not always clearly show when support had been provided.
“Records relating to people's care and risk assessments were not always current or accurate.” from the report
Quality checks missed problems
seriousThe home's audits did not always identify gaps in care records. Some audits found problems but did not clearly state what action was needed or who was responsible.
“The provider and registered manager did not always operate effective systems to monitor, assess and improve the quality of care.” from the report
Further activity development was needed
minorActivities had improved, but the manager still had plans to improve access to meaningful activities and the local community, including for people cared for in bed.
“The registered manager and provider had plans to promote and develop meaningful activities within Charnwood House.” from the report
- 01How have you corrected the care and risk records, especially information about choking risks and changes in people's support?
- 02How do you check that repositioning and other care has been recorded accurately and promptly?
- 03What actions came from your care plan, activities and health and safety audits, and who is responsible for completing them?
- 04How will you show that the improvements required after this inspection have been completed?
- 05What meaningful activities are available for people who are cared for in bed, and what further activities or community access are planned?
This was an unannounced follow-up inspection that assessed all five key questions and included infection prevention and control checks, following the previous Inadequate inspection. This explanation was written from the published report of 25 August 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.
What inspectors found, March 2023
Rated Inadequate and placed in special measures; inspectors found serious safety, safeguarding and management failures.
This was an unannounced inspection over three days. Inspectors spoke with people, relatives, staff and professionals. They reviewed care plans, risk assessments, medicines records, staff files and the home's monitoring systems.
Inspectors found people were not always protected from harm. Risks were not fully assessed, safeguarding concerns and incidents were not always reported, medicines records were not always safe, and parts of the building were unclean or poorly maintained.
Care was not always planned around people's choices and needs. People did not always receive meaningful activities, and the home did not consistently follow the Mental Capacity Act. Some staff training and communication also needed improvement.
There were positive findings. Relatives described staff as kind, people received varied food and drinks, recruitment checks were completed, and staff received induction and support. However, the overall rating was Inadequate, and the home was placed in special measures.
Food and drinks
People were offered regular meals, snacks and drinks. Inspectors saw a good selection of food and supportive mealtime care.
“People were provided with regular meals, snacks and fluids by staff to ensure their nutrition.” from the report
Staff support
Staff received induction, ongoing training, supervision and competency checks. Team morale was described positively.
“Staff received regular support this included; supervisions, appraisals, training and team meetings.” from the report
Recruitment checks
The provider used safer recruitment practices and completed DBS checks before staff provided care.
“The provider completed DBS checks on staff prior to them providing care.” from the report
Safeguarding failures
seriousFive incidents between people had not been reported to the local authority safeguarding team. Some injuries and possible abuse concerns were not properly reported or investigated.
“Safeguarding incidents were not always identified and reported to keep people safe from harm.” from the report
Risk and medicines
seriousRisk assessments did not always give staff clear safety instructions, and accident reviews did not consistently identify patterns. Medicines records and instructions were incomplete in several areas.
“People's medicines were not safely managed and administered at all times.” from the report
Poor environment and infection control
seriousInspectors found unclean areas, unsuitable PPE use, damaged equipment and building waste partly blocking fire escapes.
“We found building waste material obstructing fire exits, broken radiator covers, perished furniture and equipment not in a good state of repair.” from the report
Weak management oversight
seriousThe provider's monitoring systems failed to identify several serious problems. Required notifications to CQC were not always made.
“There was a lack of governance processes and systems in place to help ensure the safe running of the service.” from the report
- 01What has been done to ensure all safeguarding incidents, unexplained injuries and accidents are reported and investigated?
- 02How are medicines now checked, including pain patches, PRN medicines, creams and Medicine Administration Records?
- 03What repairs, cleaning and fire-exit checks have been completed since the inspection?
- 04How are people now involved in care-plan reviews, Mental Capacity Act decisions and DoLS conditions?
- 05What meaningful activities and outings are now available for people in bedrooms and for people living with dementia or a learning disability?
This was an unannounced inspection of the care home covering all five key questions, including infection prevention and control and the systems used by the new provider. This explanation was written from the published report of 18 March 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.
Every inspection of Charnwood House Nursing Home
4 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- August 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Charnwood House Nursing Home →
- March 2023InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
Read what inspectors found at Charnwood House Nursing Home →
- February 2021Inspected but not ratedSafe: Inspected but not rated
- December 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2022
Registered with the Care Quality Commission on 14 February 2022.
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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38 live-in carers within about an hour of Gloucestershire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,030 to £1,360 a week. 31 can care for a couple. 12 years' experience on average.
“She was very caring, kind and patient to all his needs, she built up a wondetful rapport with him, she was dedicated and was there for him through good times as well as through the tough times”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.