CQC report explained · a nursing home
What the CQC found at Charnwood Oaks Nursing Home
Rated Inadequate: inspectors found the home performing badly and the CQC has taken enforcement action.
What inspectors found, March 2022
Requires Improvement; inspectors found unsafe gaps in risk assessments and infection control, although staffing and medicines management had improved.
This was an unannounced, focused inspection on 12 January 2022. Inspectors looked mainly at Safe and Well-led, including infection control and visiting arrangements. They spoke with people and staff, observed care, and checked care, medicines and management records.
The home did not always keep people safe. Risk assessments were missing for some known risks, including COVID-19, isolation and some behaviours linked to dementia. Inspectors were not assured that the home could always prevent or manage infection outbreaks safely.
Staffing had improved, and medicines were generally managed safely. The managers had also acted on some earlier concerns, but oversight was still not reliable enough. The overall rating remained Requires Improvement, as did Safe and Well-led.
Improved staffing
Staffing levels had increased, with temporary staff used to fill pandemic-related vacancies. Further plans were in place to improve staffing numbers, skills and deployment.
“Staffing levels were increased to support safe care.” from the report
Medicines
People received their medicines as prescribed. Staff were assessed as competent and records were completed consistently, apart from a minor storage issue involving fluid thickeners.
“People received their medicines as prescribed by their doctor. Staff were competent in the safe management and administration of medicines.” from the report
Personal protective equipment and visits
Inspectors were assured that PPE was being used safely and that visits were being facilitated in line with current guidance.
“We were assured the provider was facilitating visits for people living in the home in accordance with the current guidance.” from the report
Action after earlier concerns
The provider had acted on some problems found at the previous inspection, and systems were in place to share learning with staff.
“There were systems in place to share learning and improvement within the staff team.” from the report
Missing risk assessments
seriousAssessments were not always completed for known risks, including COVID-19 and risks affecting people's welfare. Staff therefore did not always have the information needed to provide safe support.
“Risk assessments were not always in place. Assessments for known risk to people's welfare were not always completed.” from the report
Infection control and admissions
seriousThe home did not always follow its admissions policy for people arriving from hospital. There were also no clear protocols for people who refused lateral flow tests, despite a COVID-19 outbreak.
“Where people had refused to complete COVID-19 lateral flow tests, there were no protocols in place to mitigate risk to them and others.” from the report
Weak management oversight
needs fixingManagers did not consistently monitor risk assessments, safe admissions, isolation arrangements or staff testing. This limited their ability to identify and reduce risks promptly.
“The managers did not always maintain full oversight of areas of the service which could result to people being at risk of unsafe care.” from the report
Minor storage issue
minorStaff did not follow the home's protocol for storing fluid thickeners. Managers said they would address this immediately.
“We identified a minor issue where staff had not followed the provider's protocols in the storage of fluid thickeners.” from the report
- 01What risk assessments are now in place for my relative, including risks linked to COVID-19 and any dementia-related behaviours?
- 02How do you safely manage people arriving from hospital, including isolation and people who may find isolation difficult?
- 03What is your current process if a resident refuses a lateral flow test during an outbreak?
- 04How do you check that staff testing, risk assessments and infection-control arrangements are being monitored and updated?
- 05What progress has been made on the action plan requested by CQC after this inspection?
This was a focused inspection of Safe and Well-led, including infection control and visiting arrangements; the other key questions were not assessed in this report. This explanation was written from the published report of 15 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, September 2021
Charnwood Oaks Nursing Home was rated Requires Improvement; inspectors found serious gaps in risk management, records, infection control and oversight.
This was an unannounced, focused inspection on 17 August 2021. Inspectors looked mainly at whether the home was safe and well-led. They spoke with people, relatives and staff, observed care, and checked care, medicines, staffing and management records.
Inspectors found that known risks were not always assessed or managed. Problems included unsafe bedrails, incorrect pressure mattress settings, incomplete repositioning records, poor investigation of injuries, gaps in infection control and concerns about staffing levels. Some people’s dietary needs were also not consistently met.
Medicines were managed safely and staff were recruited safely. However, the home’s checks and audits had not found the problems inspectors identified. The overall rating remained Requires Improvement, as did Safe and Well-led. The other three areas were not inspected during this visit, so their earlier ratings were carried forward.
Medicines
Medicines records were completed properly. Staff had the training and competency checks needed to administer medicines safely.
“Medicines were administered safety. Staff had the training required to administer medicines.” from the report
Safe recruitment
The home used references and DBS checks as part of its recruitment process.
“Safe recruitment practices were in place and the provider used references and the Disclosure and Barring service (DBS)” from the report
People felt safe
The people inspectors spoke with said they felt safe with staff.
“One person said, "I have never felt unsafe." Another person told us, "I feel safe with the staff.” from the report
Working with professionals
Staff worked with outside health professionals, including speech and language therapists, the falls team and dieticians.
“Staff worked closely with external professionals. We saw referrals were made to speech and language therapists, falls team and dieticians.” from the report
Unmanaged risks
seriousSome known risks did not have assessments or clear guidance for staff. Inspectors also found bedrails that were too low and pressure mattresses set incorrectly.
“Risk assessments were not completed for all known risks. For example, there were no risk assessments in place for when a person was unable to use a call bell” from the report
Injuries and infection control
seriousSome injuries were not recorded or investigated properly. PPE was not always used correctly, and risk assessments were missing for staff who refused COVID-19 testing.
“We were not assured that the provider was using PPE effectively and safely or that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Incomplete care records
seriousRecords did not consistently show that people had been repositioned or given food suitable for their dietary needs. This could increase risks to their health.
“Records of care tasks had not been completed consistently. We found concerns with the recording of repositioning checks to protect people from pressure damage and food charts for people who requires special diets.” from the report
Staffing and training
needs fixingStaff and one person said there were not enough staff at times. Some staff still needed training in dementia, first aid and nutrition.
“Staff told us that due to staffing levels they were unable to ensure staff were present in communal areas.” from the report
Weak oversight
seriousThe provider’s audits did not identify the problems inspectors found. Feedback from people, relatives and staff was not consistently collected or used to improve care.
“The provider had failed to ensure adequate systems and processes were in place to assess, monitor and improve the quality and safety of the care provided.” from the report
- 01What has been done to complete risk assessments for people who cannot use a call bell or who have communication needs?
- 02How are you checking bedrails, pressure mattress settings and repositioning records for each person?
- 03How do you investigate and record unexplained injuries and falls, including unwitnessed falls?
- 04How are you making sure staff wear the correct PPE and complete required COVID-19 testing or risk assessments?
- 05How are staffing levels and staff training in dementia, first aid and nutrition being improved?
This was a focused inspection of Safe and Well-led, with infection control also reviewed; Effective, Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 15 September 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 Charnwood Oaks Nursing Home
5 rated inspections over 6 years: the service has held its Requires improvement rating throughout.
- March 2022Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2021Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- November 2019Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- July 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- August 2014
Report published without a new overall rating.
- April 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- May 2011
Report published without a new overall rating.
- February 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 20 January 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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