CQC report explained · a nursing home
What the CQC found at Chatterwood Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, October 2020
Rated Requires Improvement; inspectors found kind and effective care, but incident reporting and service leadership were not consistent enough.
This was a follow-up inspection on 30 September 2020. Inspectors reviewed care records, medicines records, training and recruitment files, policies and quality checks. They also spoke with people, relatives, staff and health professionals, and observed care.
The home had improved since its previous Inadequate rating. Inspectors rated Effective, Caring and Responsive as Good. They found enough staff, safe recruitment, safely managed medicines, good care planning, kind care and support for people's nutrition, health and activities.
There were still important weaknesses. Some unexplained bruises and injuries had not been recorded or investigated as possible abuse. Relatives did not always feel involved in care planning or the running of the home. The home did not have a registered manager at the time, although a new manager had started that day.
The home remained in breach of Regulation 13 about safeguarding. It was no longer rated Inadequate or in Special Measures. The provider was asked for an action plan and CQC said it would monitor progress and return.
Kind and respectful care
People and relatives spoke positively about staff. Inspectors observed staff being patient, reassuring and respectful, including during personal care and support with eating.
“We observed caring interactions between staff and people.” from the report
Improved care outcomes
Risk management had helped some people gain weight and improve their skin. Care plans had been reviewed and reflected people's current needs.
“Records showed the management of risks to people had resulted in improvements to their health and wellbeing.” from the report
Enough staff and safe recruitment
People and relatives said there were enough staff. Recruitment checks were in place, and inspectors saw call bells answered promptly.
“We did not receive any concerns about staffing levels, and we observed call bells were answered promptly during our inspection visit.” from the report
Injuries and possible abuse
seriousSome unexplained bruises and injuries were not recorded or investigated as incidents of possible abuse. Inspectors said this placed people at risk of harm.
“This placed people at risk of harm.” from the report
Incident reporting
seriousNot all incidents were included in the provider's monthly reports or identified by its checks. The provider introduced a new recording and auditing process during and after the inspection.
“There was not a consistent approach to reporting and investigating unexplained bruising.” from the report
Family involvement
needs fixingRelatives said they had not always been involved in care planning or care plan reviews. The provider said it planned to improve communication after the effects of the Covid-19 pandemic.
“Relatives told us they were not involved in care planning although they were informed of concerns or incidents.” from the report
Oral care records
needs fixingFor one person who often refused oral care, records showed no tooth cleaning for 28 days. It was not clear what staff had done to support that person's oral health.
“However, it was not clear what action was taken by staff to support the person's oral health in these circumstances.” from the report
- 01What new process is now used to record, investigate and review every injury, bruise and other incident?
- 02How will you show that possible safeguarding incidents are reported to the right people and that lessons are learned?
- 03How will my relative and our family be involved in care planning and care plan reviews?
- 04Who is currently managing the home, and what progress has been made towards registering the manager?
- 05What support is given when a person refuses oral care, and how is this recorded?
This was a follow-up inspection of the previous concerns, with infection prevention and control also reviewed because of the Covid-19 pandemic; all five key questions were rated at this inspection. This explanation was written from the published report of 30 October 2020 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, October 2019
Rated Inadequate and placed in special measures; inspectors found serious failures in safety, consent, staff training, dignity and management.
This was an unannounced inspection on 04 July 2019. Inspectors spoke with eight people, five relatives and 12 staff. They observed care and reviewed care records, medicines records, staff files and management records.
The inspectors found people were at risk of avoidable harm. Unexplained injuries were not always reported or investigated. Risks were not always assessed or managed. Some people did not receive enough support with eating and drinking. Staff continued personal care when a person was distressed and had not consented. Staff training and induction were not strong enough.
The home was rated Inadequate overall. Safe, Effective, Caring and Well-led were all rated Inadequate. Responsive was rated Requires Improvement. The previous rating was Good, published on 14 January 2017.
Medicines records
Medicines were stored securely and records of medicines received, given and disposed of were accurate.
“Accurate records were maintained of medicines received into the service, administered and disposed of.” from the report
Infection control
Inspectors found good infection prevention measures. Staff used protective equipment and the home was clean and free from bad odours.
“The service managed the control and prevention of infection well.” from the report
Activities and community links
The home offered activities and had links with community groups and services to support people's interests and preferences.
“Staff had developed links to other resources in the community to support people's needs and preferences.” from the report
Complaints handling
Complaint records showed that complaints had been managed appropriately and action had been taken.
“Records of complaints were maintained and reflected these had been managed appropriately and action taken to address them.” from the report
Unexplained injuries
seriousInspectors found three people with unexplained injuries. Records did not show that the injuries had been recognised, reported or investigated, leaving a risk of further harm.
“A failure to recognise possible abuse, a lack of reporting, records and investigation into unexplained injuries meaning people were at risk of recurring harm because the cause of the injuries had not been established.” from the report
Consent and distress
seriousStaff continued personal care while a person was distressed and objecting. Records did not show the required capacity assessment or best interests decision.
“This meant people were receiving support that they had not consented to and that had not been agreed in their best interests.” from the report
Weight loss and nutrition
seriousPeople with significant weight loss were not monitored closely enough. The report found missing food intake monitoring, limited action and no evidence of dietician involvement where needed.
“The failure to take all reasonably practicable action to mitigate risks to people from weight loss was a breach of Regulation 12 of the Health and Social Care Act 2008” from the report
Staff training
seriousNewer staff had received little or no training, and there was no overall training plan. Staff administering medicines had not received recognised medicines training.
“The lack of training, assessment of staff competence combined with our observations demonstrated staff were not fully supported to undertake their role effectively.” from the report
Dignity and respect
seriousInspectors saw people left without timely support and heard concerns about abrupt or disrespectful staff approaches. Similar concerns had been raised before but had not led to improvement.
“Our observations, staff comments and the meeting records demonstrated systematic concerns about staff practice being disrespectful and undignified.” from the report
Weak management checks
seriousAudits and policies had not identified or corrected serious problems. Incidents, accidents and near misses were not always reported, recorded or investigated.
“Governance systems failed significantly to protect people from the possibility of abuse or harm and were not effective in identifying areas for improvement.” from the report
- 01What has changed since this inspection to ensure unexplained injuries are reported, recorded and investigated?
- 02How do you now assess capacity and record best interests decisions when someone refuses personal care or medicines?
- 03How do you monitor people's weight, food intake and nutrition, and when do you involve a dietician?
- 04What training and competency checks have all staff completed, including medicines, dignity, behaviour and nutrition training?
- 05What conditions and monthly reports were required by CQC, and what evidence can you show that they have been completed?
This was a planned, unannounced inspection covering all five key questions, including both the premises and the care provided. This explanation was written from the published report of 22 October 2019 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 Chatterwood Nursing Home
3 rated inspections over 4 years: the service has slipped, from Good to Requires improvement.
- October 2020Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2019Inadequatedown from GoodSafe: InadequateEffective: InadequateCaring: InadequateResponsive: Requires improvementWell-led: Inadequate
- January 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2014
Report published without a new overall rating.
- March 2014
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 17 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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