CQC report explained · a residential care home
What the CQC found at Chaxhill Hall
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Medicines were not always administered as prescribed and records and procedures were not always followed. Inspectors also found improvements in risk management, staffing, safeguarding and infection control.
- Effective?
- Good
- This area was not inspected during this focused visit. The report does not give a rating for this question in this inspection.
- Caring?
- Good
- This area was not inspected during this focused visit. The report does not give a rating for this question in this inspection.
- Responsive?
- Good
- This area was not inspected during this focused visit. The report does not give a rating for this question in this inspection.
- Well-led?
- Requires improvement
- Leadership and quality monitoring had improved, but audits did not always show clearly what actions were complete. Oversight of medicines management still needed to improve.
What inspectors found, December 2022
Chaxhill Hall is rated Requires Improvement; medicines were not always given safely, although inspectors found improvements in safeguarding, risk management and leadership.
This was an unannounced focused inspection. Inspectors visited on 9 and 10 November 2022, with inspection activity ending on 15 November. They spoke with people, relatives and staff, observed care, and checked care records, medicines records, recruitment files and management audits.
The main concern was medicines. Staff did not always follow the correct process or keep accurate records, and one person did not receive medicines as prescribed. No-one was harmed, but people were put at risk. Immediate action was taken during the inspection, including a review with the person's GP and more monitoring of staff practice.
There had been improvements since the previous inspection. Safeguarding arrangements, risk assessments, infection control, cleaning and oversight by the provider had improved. However, medicines management still breached Regulation 12, and audits did not always clearly show which actions had been completed.
The overall rating remained Requires Improvement. Safe and Well-led were both rated Requires Improvement. The other three areas were not inspected during this visit, so their earlier ratings were used when calculating the overall rating.
Improved risk management
Risks to people's health, safety and welfare were identified, acted on and routinely reviewed. The home used equipment such as sensor mats to help reduce risks.
“Risks to people's health safety and welfare, were identified and action was taken to reduce these risks.” from the report
Safeguarding improved
The home had arrangements to report and respond to safeguarding concerns and was no longer in breach of the safeguarding regulation.
“Arrangements were in place to safeguard people from abuse and to correctly respond to safeguarding concerns.” from the report
Infection control and staffing
Inspectors found improved cleaning and infection control. They also found enough staff with suitable skills and experience to provide care and keep the home clean.
“Enough staff, with the right skills and experience, were deployed to deliver people's care, to support people with social activities and to ensure the home was kept clean.” from the report
Visible leadership
The registered manager worked alongside staff, attended daily handovers and responded positively to feedback. Staff said they felt positive and invested in the service.
“The registered manager was visible to people who used the service and their visitors.” from the report
Medicines not always managed safely
seriousStaff did not always follow the admission process or safe medicines procedures. One person did not receive medicines as prescribed, creating a risk of harm.
“This puts people at risk of not receiving medicines safely and as prescribed.” from the report
Audits did not always show completed actions
needs fixingThe home had improved its auditing system, but records did not always make clear what had been completed and what was still outstanding.
“Although completed and we saw actions for improvement identified and recorded, the audits did not always provide clear information about what actions had been completed.” from the report
Previous medicines problem repeated
seriousThe home remained in breach of the medicines regulation from the previous inspection. More time and monitoring were needed to make the improved systems reliable.
“We have identified a repeated breach in relation to safe medicines management at this inspection.” from the report
- 01What immediate changes were made after the medicines error found during the inspection?
- 02How do you now check that medicines are given as prescribed and recorded correctly?
- 03How often are medicines practices monitored, and who reviews the results?
- 04How do your audits show which improvement actions are complete and which are still outstanding?
- 05What progress has been made on the action plan requested by the CQC?
This was a focused inspection of Safe and Well-led only; the other ratings carried over from the previous inspection. This explanation was written from the published report of 16 December 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, March 2021
Requires Improvement; inspectors found risks with infection control, medicines, safeguarding and management systems.
This was an unannounced focused inspection. Inspectors visited on 7 January, 9 February and 11 February 2021. The first visit took place during a COVID-19 outbreak, so they initially looked only at infection control.
The home had enough staff with suitable skills. However, infection control arrangements were not robust, medicines were not always managed safely, and some safeguarding concerns had not been reported or investigated properly. Changes in people's weight and accidents were also not always acted on quickly.
The home was rated Requires Improvement overall, and for Safe and Well-led. The rating fell from Good at the previous inspection. The other three areas were not inspected during this visit, so their previous ratings were used.
Staffing
Inspectors found enough staff to meet people's needs, with appropriate skills and experience.
“There were enough staff on duty to meet people's needs.” from the report
Staff skills
The staff team had the skills and experience inspectors considered appropriate for the people living in the home.
“People were supported by staff with the appropriate skills and experience.” from the report
Immediate infection control action
The registered manager acted quickly after inspectors raised concerns. Cleaning was improved and new systems were being introduced.
“Immediate improvements to cleaning were made and improved systems were being implemented to reduce infection transmission risks, in line with national guidance.” from the report
Working with other professionals
The home worked with the local authority and commissioners to make changes. Relatives were informed when people became unwell or were injured after a fall.
“Records demonstrated people's relatives had been informed and updated when their relative became unwell or was injured as a result of a fall.” from the report
Infection control
seriousCleaning records and infection control checks were not detailed or regular enough. The home did not have a clear plan for managing another outbreak.
“Cleaning arrangements were insufficient to safely reduce transmission risks within the service.” from the report
Medicines
seriousOne person's repeated refusal of medicines was not referred promptly to a health professional. Records for creams and ointments did not show whether medicines had been given as prescribed.
“People's medicines had not always been managed safely.” from the report
Safeguarding responses
seriousSeveral safeguarding incidents had not been reported to the local authority. One allegation was not reported to the police or investigated appropriately.
“The provider had not always responded to safeguarding incidents to ensure they were reported and investigated in line with local processes and legal requirements.” from the report
Management checks and records
seriousAudits did not reliably identify safety problems. Care, medicines and recruitment records were not always accurate or complete.
“The systems in place to monitor and improve the quality of the service had not always been established and operated effectively to maintain the safety of the service.” from the report
Risk reviews
needs fixingChanges in people's weight and accident reports were not always acted on promptly. Care records did not always show what action staff had taken.
“Risks to people were not always reviewed and acted upon in a timely manner.” from the report
- 01What changes have you made to cleaning, infection control audits and your plan for managing another COVID-19 outbreak?
- 02How do you now identify and respond when someone refuses medicines repeatedly?
- 03How are safeguarding concerns reported to the local authority and police, and how do you check that investigations are completed?
- 04How often are accident reports, weight changes and other changes in risk reviewed now?
- 05What checks are in place to make sure care, medicines and recruitment records are complete and accurate?
This was a focused inspection of Safe and Well-led only; the other three key questions were not inspected and their previous ratings were used. This explanation was written from the published report of 26 March 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 Chaxhill Hall
4 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- December 2022Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- May 2018Goodstayed GoodSafe: GoodWell-led: Good
- December 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2014
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 22 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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