CQC report explained · a residential care home
What the CQC found at Cheriton Care 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, March 2023
Requires Improvement; inspectors found progress since the previous Inadequate rating, but ongoing safety, staffing, dignity and management problems, and the home is no longer in Special Measures.
This was an unannounced inspection on 9 and 11 January 2023. Inspectors spoke with people, relatives, staff and a health professional. They observed care and mealtimes, checked the building and reviewed care, medicine, staffing and management records.
The home had improved since its previous inspection, when it was rated Inadequate and placed in Special Measures. However, inspectors found that some risks were not properly managed, staffing was not suitably organised, areas were not clean, and records were incomplete or contradictory.
People and relatives generally said people felt safe and were cared for. Medicines, food, training and access to health professionals were areas of strength. However, inspectors found that people's dignity, personal interaction, activities and involvement in care were not always properly supported.
The overall rating is Requires Improvement. Safe, Caring, Responsive and Well-led were also rated Requires Improvement. Effective was rated Good. The home remained in breach of several regulations, although it was no longer in Special Measures.
Medicines
Medicines were administered as prescribed, with no gaps seen in the records. Staff were trained and their competency was checked.
“The medicine administration records viewed, showed medicines were given as prescribed, with no gaps in administration.” from the report
Food and nutrition
People were offered meal choices, drinks and alternative food. Staff understood specialist needs such as thickened drinks, and records were kept of food and fluid intake.
“People were offered meal choices and drinks. Alternative food options were available if people requested it.” from the report
Staff training
Staff received induction, shadowing and training relevant to their roles. This included safeguarding, moving and handling, nutrition, infection control and fire safety.
“Staff had access to training considered mandatory by the provider such as safeguarding, moving and handling, nutrition and hydration, infection control, person centred care and fire safety.” from the report
Health support
People had access to a range of health professionals, and information about reviews was included in care plans.
“People had access to health professionals such as the GP, an advanced nurse practitioner, Speech and language therapist, physiotherapist, and community mental health team.” from the report
Improvement since the last inspection
The provider had acted on earlier recommendations and introduced new systems for audits, records and learning from incidents. The service improved from Inadequate and left Special Measures.
“During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions.” from the report
Staffing and cleaning
seriousStaff were covering several roles, including care, meals, laundry and cleaning. Inspectors found that this affected care, activities and cleanliness, with some areas dirty or unhygienic.
“Staff were not suitably deployed, and roles were not covered on shift, which detracted the care staff from people's care.” from the report
Privacy and dignity
seriousStaff did not always knock before entering bedrooms or interact respectfully. Some personal care was carried out in communal areas, and people had limited conversation and social contact.
“People's privacy, dignity, respect and independence was not promoted.” from the report
Inaccurate records and audits
seriousSome records contradicted each other or were incomplete, including records about treatment choices, appointments, bathing and staffing. Audits did not identify all the problems inspectors found.
“People's records were contradictory.” from the report
- 01What staff numbers and roles are guaranteed on each day and night shift, and who is responsible for care, meals, medicines, activities, laundry and cleaning?
- 02How are call bells checked now, and what happens if a person does not have access to a working call bell?
- 03How do staff protect people's privacy when entering bedrooms, giving medicines or providing personal care?
- 04What regular activities are now available, and how are they matched to each person's interests and communication needs?
- 05How are care plans and records checked for contradictions, missing information and accurate staffing records?
This was a focused inspection of the provider's action plan and legal compliance, with infection prevention and control also reviewed under Safe; the inspection rated all five key questions. This explanation was written from the published report of 1 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. The report was longer than we could read in one go; the later sections may not be reflected.
What inspectors found, May 2022
Rated Inadequate and placed in special measures; inspectors found serious risks to safety, care, dignity and management.
Inspectors visited the home without warning on 4 March and 4 April 2022. They spoke with people, staff, relatives and professionals, observed medicines and staff handovers, and reviewed care plans, staff files, audits and safety records. Some records could not be found or were not provided.
They found people were at risk of avoidable harm. Problems included unsafe fire exits and windows, poor infection control, stained and wet bedding, unclear guidance about food and drinks, and staff not responding when someone was coughing while eating. The building also had maintenance problems.
Care plans did not always describe people's full needs. Staff did not consistently support people's choices, dignity, activities or dietary needs. The home also had serious weaknesses in mental capacity and liberty safeguards, staff checks, complaints records and oversight by the provider.
The overall rating was Inadequate. Safe, Effective and Well-led were rated Inadequate. Caring and Responsive were rated Requires Improvement. The home was placed in special measures, meaning the CQC said it would keep the service under review and normally reinspect within six months.
Medicines practice
Inspectors found that medicines were administered safely and records showed when medicines had been given.
“Staff followed safe practice when they administered people's medicines.” from the report
Safer recruitment
Recruitment files contained the required identity, reference and criminal record check documents.
“People were protected through safe recruitment practices at the service.” from the report
Access to healthcare
People were supported to contact healthcare professionals, including GPs, district nurses and physiotherapists, when needed.
“People were supported to access healthcare services.” from the report
Positive feedback
Some people and relatives said they felt safe and described staff as kind, helpful and respectful.
“Another relative said "Overall the care my (family member) receives at Cheriton is very good.” from the report
Risk of injury and choking
seriousPeople could access an upstairs fire escape through an unsafe door or window. Inspectors also found staff did not respond when someone was coughing while eating, and specialist advice about thickened drinks was not followed.
“There was a risk people could easily get on to the fire escape and fall down the steps.” from the report
Poor infection control
seriousMasks were not always worn correctly. Inspectors found stained bedding, a wet valance, an unpleasant-smelling room and storage practices that could spread contamination.
“This showed there were poor standards of hygiene at the home.” from the report
Incomplete and unclear care plans
seriousImportant information about mobility, medical history, diabetes, eating and other needs was missing or contradictory. This could lead to inconsistent or unsafe support.
“Care plans did not identify people's full range of needs and were not always person-centred.” from the report
Unlawful restrictions risk
seriousSome liberty safeguard applications appeared inappropriate, records were not readily available and evidence was missing for some renewals and restrictions.
“We could not be assured the service was acting lawfully through practices used at the home.” from the report
Dignity and choice
seriousInteractions were often task-based. Inspectors saw limited conversation and choice, and found some people were not well-groomed or were wearing stained or unclean clothing.
“This made assumptions about people's abilities to manage independently.” from the report
Weak management oversight
seriousThe provider could not find important records when the manager was absent, and audits did not identify the range of problems found during the inspection.
“This demonstrated the home did not have an adequate management structure in place and poor provider oversight of the service.” from the report
- 01What has been done to secure the upstairs fire exit door and window, and when were all fire safety repairs completed?
- 02How do you now make sure staff wear protective equipment correctly and that bedding, rooms and laundry areas are kept clean?
- 03How are care plans checked so that choking risks, diabetes, mobility and medical needs contain clear, person-specific instructions?
- 04How do you check that liberty restrictions and sensor mats are legally authorised and that staff can access the relevant records?
- 05What action has been taken under the special measures action plan, and can we see evidence of the improvements and the latest inspection outcome?
This was an unannounced inspection covering all five key questions, infection prevention and control, the premises and care provided, although inspectors could not review all the records they requested. This explanation was written from the published report of 25 May 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. The report was longer than we could read in one go; the later sections may not be reflected.
Every inspection of Cheriton Care Home
4 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- March 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: GoodCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- May 2022Inadequatedown from Requires improvementSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- April 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- April 2021
Registered with the Care Quality Commission on 21 April 2021.
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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