CQC report explained · a nursing home
What the CQC found at Chesham Leys
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found improvements to fire safety checks, safe medicines management, equipment checks and staff recruitment. They recommended clearer signs in the laundry to reduce the risk of cross infection.
- Effective?
- Good
- People's needs were assessed and reviewed, and staff received induction, training and supervision. People were supported with nutrition, healthcare and decisions made under the Mental Capacity Act.
- Caring?
- Good
- Staff treated people with kindness, dignity and respect. Inspectors saw staff engaging warmly with people and supporting their privacy, independence and relationships.
- Responsive?
- Good
- Care plans reflected people's preferences, cultural needs and changing circumstances. Activities and complaint procedures were available, but end-of-life wishes were not fully recorded and more work was needed on accessible information.
- Well-led?
- Good
- Inspectors found experienced management, clear values, good communication and systems for learning from incidents. They recommended better recording, checking and sign-off of actions from audits.
What inspectors found, January 2018
Chesham Leys was rated Good; inspectors found safe, kind and responsive care, with some areas needing further improvement.
This was an unannounced inspection on 14 and 15 November 2017. Inspectors spoke with people living at the home, visitors, staff and community professionals. They observed care and checked care plans, medicines records, staff files, training records and safety checks.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found that people were safe, treated with dignity, supported with their health and nutrition, and offered activities. Medicines, recruitment, fire checks and equipment safety had improved since the previous inspection.
Inspectors made recommendations about laundry procedures, accessible information, end-of-life care and recording actions from audits. They also found that regular residents' meetings had not taken place since 2016. These were improvements to work on, rather than breaches of regulations.
Improved safety
The home had addressed earlier concerns about fire safety. Inspectors found regular checks, emergency plans, trained staff and safe equipment.
“On this occasion we found improvements had been made to ensure people received safe care that was appropriate to their needs.” from the report
Kind and respectful care
People told inspectors that staff were kind and friendly. Observations showed staff protected privacy, encouraged independence and took an interest in people's wellbeing.
“People were treated with kindness, respect and compassion.” from the report
Activities and choice
People were supported to choose food, clothing and activities. The home offered music, crafts, exercise, reminiscence and other social activities.
“The service supported people to take part in social activities.” from the report
Better staff support
Since the previous inspection, staff had received structured induction, supervision and professional development. Nursing staff also had a clinical induction.
“On this occasion we found improvements had been made.” from the report
Open management
The registered manager was approachable and understood responsibilities such as reporting serious incidents and being open when things went wrong.
“The service had an experienced registered manager.” from the report
End-of-life planning
needs fixingTwo care plans did not fully record people's wishes about end-of-life care. The home did not have links with specialist palliative services and staff had not received end-of-life care training.
“Neither had been completed fully, so the person's wishes were not appropriately recorded.” from the report
Laundry workflow
minorThe laundry had separate entrance and exit doors, but there were no signs showing the required one-way route. Inspectors said this could increase the risk of contamination.
“There was no signage to show which way staff needed to go in or out to make sure a one way system was used.” from the report
Residents' meetings
needs fixingNo residents' meetings had been held since 2016, and the home could not show records of other meetings led by senior staff. Management planned to introduce meetings for each floor.
“The registered manager told us there had not been any residents' meetings since 2016.” from the report
Audit actions
needs fixingThe action plan did not clearly include all points from an external audit, and inspectors could not see that outcomes had been checked and signed off.
“We were unable to see this had been done from the action plan we were shown when at the service.” from the report
Accessible information
needs fixingSome work had started, such as producing menus with pictures, but inspectors recommended further work so people could access information about their care and treatment.
“We recommend further work is undertaken to make sure people have access to information about their care and treatment.” from the report
- 01What changes have been made to end-of-life care training, links with palliative care services and recording people's wishes?
- 02How do residents now share their views, and how often are residents' meetings held?
- 03What signs and procedures are now used in the laundry to keep clean and soiled items separate?
- 04How are actions from audits recorded, checked and signed off as completed?
- 05How can people with communication needs access information about their care and treatment?
This was an unannounced inspection of the overall service and all five CQC questions, following an earlier inspection in 2016 that found concerns about fire safety and staff support. This explanation was written from the published report of 6 January 2018 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, December 2016
Requires Improvement; inspectors found kind and responsive care, but concerns remained about fire checks, staff support, training and records.
Inspectors visited on 31 October, 01 November and 09 November 2016. The first visit was unannounced. They spoke with people, relatives, staff and healthcare professionals, observed care, and checked care plans, medicines records, recruitment files and staff training records.
The home had improved since the previous inspection in October 2015. Medicines management, infection control, nutrition and care planning had improved. People were treated with kindness, their preferences were respected, and activities had improved.
However, routine fire safety checks were not always recorded or carried out as expected. Some staff did not have regular supervision or up-to-date training. Fluid charts, cream application records and other records were not always completed properly. These issues led to breaches of regulations 12 and 18.
The overall rating was Requires Improvement. Safe, effective and well-led were rated Requires Improvement. Caring and responsive were rated Good. This means the home had important strengths, but improvements were needed to make care consistently safe and well managed.
Kind and respectful care
People and relatives generally described staff as kind, polite and compassionate. Inspectors observed staff smiling, making eye contact and explaining care.
“People were treated with kindness, affection and compassion.” from the report
Personalised care
Care plans recorded people's needs, routines and preferences. Staff could explain how they supported individuals and involved families where appropriate.
“Care plans were personalised and detailed daily routines specific to each person.” from the report
Improved nutrition
The home had improved its approach to identifying and supporting people at risk of malnutrition. People were offered suitable food, snacks and drinks.
“We saw people had been assessed for the risk of malnutrition.” from the report
Improved infection control
The home was clean and hygienic, and inspectors found safer systems for handling laundry and clinical waste.
“On this occasion we found improvements had been made. The home was clean and hygienic.” from the report
Activities and involvement
Activities had improved and included music, quizzes, creative activities, entertainers and community links. People and relatives were involved in suggesting activities.
“People were supported to take part in social activities to increase their stimulation.” from the report
Fire safety records
seriousThere were long gaps in records for fire call point, escape route and fire extinguisher checks. Fire drills had also not been carried out at the expected frequency.
“People were not fully protected from the risks associated with unsafe premises.” from the report
Staff training and supervision
seriousSome staff had no recorded supervision, probationary assessments or current refresher training. Agency nurses did not receive a clinical induction.
“This placed people at risk of receiving inconsistent or unsafe care.” from the report
Incomplete care records
needs fixingFluid monitoring charts were not always completed or evaluated. Records showing when creams and other topical preparations were applied were also inconsistent.
“However, we found records had not always improved where monitoring was required, such as fluid intake.” from the report
Agency staff continuity
needs fixingRelatives raised concerns about frequent agency staff and the effect this could have on consistency, especially for people with dementia. The home was trying to use block bookings where possible.
“The care is up and down and a bit of a lottery, it depends on who is on and the type of agency staff that are on duty.” from the report
- 01What steps have you taken to make sure all fire safety checks and fire drills are completed and recorded on time?
- 02How do you make sure every staff member receives regular supervision, probationary assessment and refresher training?
- 03How are agency nurses inducted into the home, and how do you make sure they understand each resident's nursing needs?
- 04How do you check that fluid charts and records for creams and other topical preparations are completed accurately?
- 05How do you provide continuity for people with dementia when agency staff are used?
This was a comprehensive inspection covering all five questions, with improvements and continuing concerns compared with the previous inspection in October 2015. This explanation was written from the published report of 9 December 2016 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 Chesham Leys
3 rated inspections over 2 years: the service has improved, from Requires improvement to Good.
- January 2018Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- August 2014
Registered with the Care Quality Commission on 26 August 2014.
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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