CQC report explained · a nursing home
What the CQC found at Chataway 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
- Premises risks, cleaning chemical storage, fire-drill records and medicines management were not always dealt with safely. The home had sufficient staff, safe recruitment and good infection control.
- Effective?
- Requires improvement
- New staff did not always have a comprehensive induction, and staff did not always understand the Mental Capacity Act or restrictive practice. People's needs, healthcare and food and drink support were otherwise generally well planned.
- Caring?
- Good
- Staff were kind and respectful. People were involved in decisions about their care and supported to remain independent.
- Responsive?
- Good
- Care was personalised and people were supported with relationships, activities and communication. Inspectors noted that structured rehabilitation support and advance care planning needed further development.
- Well-led?
- Requires improvement
- Audits and management oversight had not identified important safety and medicines problems, and many key audits had not been completed for five months. A new manager had been appointed, but there was no registered manager in post.
What inspectors found, December 2023
Chataway Nursing Home is rated Requires Improvement; inspectors found kind, responsive care but serious weaknesses in safety, medicines and management.
Inspectors made an unannounced visit on 24 October 2023. They spoke with people and staff, observed care, checked the premises and infection control, and reviewed care, medicines, staffing and management records.
The home was not always safe. Inspectors found delays in dealing with premises safety work, unsafe storage of cleaning chemicals, incomplete night fire-drill records and medicines problems. Two people did not always receive prescribed eye drops on time. Staff induction and understanding of the Mental Capacity Act also needed improvement.
People were treated kindly and involved in their care. They received personalised support and took part in activities and community trips. The overall rating is Requires Improvement. The ratings for Safe, Effective and Well-led changed from Good at the last inspection, published in August 2018. Caring and Responsive remained Good.
Kind and respectful staff
People said staff treated them well. Staff respected privacy and dignity and encouraged people to do things for themselves.
“People were supported and treated with dignity and respect. They were involved as partners in their care.” from the report
Personalised care
People's needs and preferences were recorded and used to plan their care. People had keyworkers and regular meetings about their support.
“People received personalised care which met their needs and reflected their preferences.” from the report
Activities and relationships
People were supported to keep relationships, join group activities and take trips in the local community.
“They took part in group activities and trips in the local community.” from the report
Staffing and recruitment
Inspectors found enough suitable staff and evidence of checks before new staff started work.
“The provider operated safe recruitment processes. References were obtained and verified.” from the report
Medicines were not always safe
seriousThere was no system to check medicine stock balances. Two people did not always receive prescribed eye drops on time, and some guidance for when-required medicines was not person-centred.
“Medicines systems and processes had not been fully established to assess, monitor and mitigate risks to the health, safety and welfare of people using the service.” from the report
Premises and fire safety
seriousOutstanding electrical and lift work had not been completed promptly. A cleaning trolley containing bleach was left where people could access it, and night fire-drill records were incomplete.
“Cleaning chemicals were not always stored safely. A cleaning trolley was left unattended on the first floor, this contained a bottle of bleach and other cleaning products.” from the report
Weak management checks
seriousAudits had not found the problems identified by inspectors, and many key audits had been delayed. The home had not had a registered manager since January 2021.
“Audits failed to identify the concerns highlighted on this inspection, particularly around medicines management and premises safety shortfalls.” from the report
Induction and training gaps
needs fixingNew staff did not always complete a comprehensive induction, including the Care Certificate, or have a previous health and social care qualification.
“The provider was unable to provide evidence that staff had completed the Care Certificate at the start of their employment or had previously obtained a qualification in health and social care.” from the report
Consent and restrictions
needs fixingStaff did not always understand restrictive practice. Consent for hourly night checks was inconsistent, with many consent forms unsigned.
“Although this was done in good intentions, we found the providers approach to obtaining people's consent was inconsistent with many consent forms not signed.” from the report
Rehabilitation model changed
needs fixingThe previous bespoke recovery model was no longer being used. Care plans contained limited information about health promotion and rehabilitation, including support for addiction and independence.
“However, at this inspection a bespoke recovery model was no longer deployed.” from the report
- 01What has been completed to address the electrical and passenger lift safety work, and can you show us the records?
- 02How do you now check medicine stocks, record who gives medicines and make sure prescribed eye drops are given on time?
- 03What induction do new staff complete before providing care, and how is their medicines competence checked?
- 04How do you record consent for hourly night checks and decide whether any restriction is in a person's best interests?
- 05Who is currently responsible for the home, and when will the new manager apply to become the registered manager?
This was an unannounced inspection that considered all five CQC questions; the report compares the findings with the previous Good rating published on 13 August 2018. This explanation was written from the published report of 2 December 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 2022
Inspected but not rated; inspectors were assured about infection control and visiting arrangements.
This was a planned, announced inspection on 19 January 2022. It was a targeted check of infection prevention, COVID-19 visiting arrangements and staffing pressures.
The inspectors were assured that the home was using personal protective equipment safely, arranging testing, managing admissions and preventing infections. They also found that visits were being facilitated in line with relevant guidance.
The home was meeting the requirement for non-exempt staff and visiting professionals to be vaccinated against COVID-19. The service was inspected but not rated, so this report does not give an overall quality rating.
Infection prevention
Inspectors were assured that the home had arrangements to prevent and manage infections, including safe use of PPE and access to testing.
“We were assured that the provider was using PPE effectively and safely.” from the report
Visiting arrangements
The home was facilitating visits for residents in line with the relevant guidance.
“We saw the provider was facilitating visits for residents in line with relevant guidance.” from the report
COVID-19 vaccination checks
The service was meeting the requirement for non-exempt staff and visiting professionals to be vaccinated against COVID-19.
“The service was meeting the requirement to ensure non-exempt staff and visiting professionals were vaccinated against COVID-19.” from the report
Inspectors raised no specific concerns in this report.
- 01How are you currently managing any staffing pressures linked to COVID-19?
- 02How do you arrange visits, and what would happen if infection levels increased?
- 03How do you make sure PPE is available and used safely by staff and visitors?
- 04How do you arrange COVID-19 testing for residents and staff?
- 05How do you check that non-exempt staff and visiting professionals meet the vaccination requirement?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19-related staffing pressures; the service was inspected but not rated overall. This explanation was written from the published report of 11 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.
Every inspection of Chataway Nursing Home
3 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- December 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2022Inspected but not ratedSafe: Inspected but not rated
- August 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2016GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- May 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 31 December 2010.
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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