CQC report explained · a nursing home
What the CQC found at Chollacott House 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
- Some risk records did not show clearly what checks had been completed or what action had been taken. Medicines were mostly given as prescribed, but one antibiotic was not always evenly spaced and some as-needed medicine protocols were missing.
- Effective?
- Good
- This key question was not inspected during this focused inspection. Its previous rating was carried forward when calculating the overall rating.
- Caring?
- Requires improvement
- People said staff were kind and caring, and inspectors saw warm interactions. However, some care was task-focused, mealtime choices were limited, and people's privacy and dignity were not always protected.
- Responsive?
- Requires improvement
- People's care records did not always contain enough personalised information. People also spent prolonged periods without meaningful activities, social contact or encouragement to use communal areas.
- Well-led?
- Requires improvement
- There was a clear management structure and staff felt supported. However, quality checks did not reliably identify problems with care records, risk monitoring, meals or social contact.
What inspectors found, November 2022
Requires Improvement; inspectors found kind staff and adequate staffing, but concerns about personalised care, dignity, activities and management checks.
This was an unannounced focused inspection on 12 and 15 September 2022. Inspectors spoke with people, relatives, staff and a health professional. They reviewed care records, medicines records, recruitment and training files, and management records.
The home had enough staff for people's nursing and care needs, and staff understood safeguarding, infection control and people's communication needs. However, care records did not always describe people's current needs or the checks needed to keep them safe. People also experienced long periods with little meaningful activity or contact with staff.
Inspectors found that some people were not always treated with dignity or given enough choice at mealtimes. Management systems had not identified or corrected these problems. The overall rating changed from Good in 2017 to Requires Improvement. The home breached regulations about person-centred care and good governance.
Safeguarding
Staff knew how to recognise and report abuse or other safeguarding concerns. The home worked with the local authority when concerns were raised.
“People were protected from the risk of potential abuse and avoidable harm by staff who had received training and recognised the different types of abuse.” from the report
Staffing and recruitment
People and relatives generally felt there were enough staff for care and nursing needs. Recruitment checks, induction, training and supervision were in place.
“People and their relatives told us there were adequate numbers of staff to meet people's nursing and care needs.” from the report
Infection control
Inspectors were assured that the home had suitable infection prevention arrangements, including safe visiting, protective equipment and outbreak management.
“We were assured that the provider was using PPE effectively and safely.” from the report
Kind relationships
People described staff as kind and caring. Inspectors saw warm interactions, and staff knew people well.
“We observed interactions between people and staff which were warm and genuine.” from the report
Communication and involvement
People and relatives were involved in care decisions where possible. Staff knew how people communicated their choices, including when people used picture cards or eye movements.
“People were involved in their care planning as much as they could be.” from the report
Incomplete risk records
seriousSome records did not show people's specific health needs, safety checks or follow-up actions clearly. This made it difficult to confirm that risks were being managed consistently.
“Some records were not complete around people's specific health requirements and did not always record the actions which had been taken to maintain a person's safety.” from the report
Person-centred care
seriousCare plans did not always contain enough current and personal information to guide staff. The report says this was a breach of Regulation 9.
“People were not provided with individualised care that met their needs.” from the report
Privacy and dignity
needs fixingPeople's bedroom doors were often open, and visitors could see people resting or see equipment such as catheter bags. Inspectors also found that care could be too focused on completing tasks.
“This did not provide assurances that staff were always supportive or respectful of people's privacy and dignity.” from the report
Limited activities and social contact
needs fixingMany people spent most of their time in bedrooms and had prolonged periods without meaningful activity or interaction. Some people sat in communal areas without staff engagement.
“People spent prolonged periods of time without access to activity or interaction.” from the report
Weak management checks
seriousQuality systems did not identify several problems with care records, risk monitoring, mealtimes and social contact. The report says this was a breach of Regulation 17.
“Robust systems and processes were not in place to demonstrate the provider had effective oversight of the service.” from the report
Medicines procedures
needs fixingOne antibiotic was not always given at evenly spaced times, and some protocols for medicines given when needed were missing. The provider acted on this during or after the inspection.
“However, 'as and when' (PRN) required medicine protocols were not always in place.” from the report
- 01How have you improved care plans so they describe each person's current health needs, risks, preferences and required checks?
- 02What changes have you made to provide regular meaningful activities and social contact for people who spend much of their time in their rooms?
- 03How do you protect people's privacy and dignity when bedroom doors are open and equipment such as catheter bags is present?
- 04How do you now check that mealtimes offer people a choice and that staff have enough time to support those who need encouragement to eat?
- 05What is the progress on the action plan following the breaches of Regulations 9 and 17?
This was a focused inspection of Safe, Caring, Responsive and Well-led; Effective was not inspected and the other rating was carried forward from the previous inspection. This explanation was written from the published report of 11 November 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, September 2017
Rated Good; inspectors found kind, safe and responsive care, with improvements made after serious earlier concerns.
This was an unannounced comprehensive inspection on 14 and 15 June 2017. Inspectors returned on 8 August after a serious safeguarding incident. They checked records, medicines, staffing and recruitment, observed care, and spoke with people, relatives, staff and health professionals.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People and relatives said they felt safe and liked the staff. Inspectors found enough staff, safe medicines systems, detailed care plans, good access to health professionals and a varied programme of activities.
The previous inspection had found four breaches and rated the service Requires Improvement. A later follow-up found two continuing breaches. By this inspection, inspectors found that improvements had been made and maintained, including better risk monitoring and quality checks.
Inspectors found some minor recording and privacy issues. These included missing records of drinks overnight, incomplete employment histories in some recruitment records, no recorded learning from some medicine errors, and continence products that were not stored discreetly.
Kind and respectful staff
People and relatives spoke highly of the staff. Inspectors observed staff communicating warmly, protecting privacy and adapting their approach to people’s needs.
“People using the service and their relatives felt all the staff were very caring and respectful.” from the report
Improved safety checks
The home had improved how it monitored pressure damage, falls, nutrition, hydration, call bells and accidents. Inspectors found the earlier safety concerns had been addressed.
“At this inspection we found improvements had been made and the above issues had been addressed.” from the report
Detailed care planning
Care records included people’s health needs, communication, preferences, personal history and family details. Staff used these records to provide personalised care.
“Care records were detailed and written in a respectful, sensitive and personalised way.” from the report
Activities and independence
People could take part in varied activities, trips and social events. Staff also supported people with personal goals and everyday independence.
“The programme was flexible depending on people's mood and interest on the day.” from the report
Better management oversight
The provider and manager had introduced regular audits and a service development plan. Inspectors found these systems were helping to identify and address problems.
“New robust systems had been put into place to monitor the quality and safety of the service.” from the report
Overnight drinks not recorded
needs fixingOn two nights, records did not show whether one person had been offered or accepted a drink between 6pm and 7am. Inspectors found no sign of dehydration and believed this was a recording problem.
“However, on two nights after 6pm, there was no record that one person was offered or accepted a drink after 6pm until 7am the next morning.” from the report
Medicine error learning was not recorded
minorThere had been five minor medicine errors in the previous 12 months. None had harmed people, but there was no record of the lessons learned or actions taken after the errors.
“We discussed with the registered manager the actions taken and lessons learnt following errors, as there was no record of these.” from the report
Recruitment records
minorSome staff files did not contain complete employment histories. The manager later confirmed that full histories were being recorded.
“However we found some deficits in the employment histories for staff.” from the report
Continence products not stored discreetly
minorInspectors saw continence products on some bedroom floors and furniture. They asked the manager to arrange more discreet storage to protect privacy and dignity.
“We did find continence products on some people's bedroom floor and furniture, which was not very discreet.” from the report
- 01How do you now make sure all food and drink offered overnight is recorded, especially for people at risk of dehydration?
- 02What changes have you made to record and review learning from medicine errors?
- 03How do you check that recruitment files contain complete employment histories and all required checks?
- 04Where are continence products stored so that people’s privacy and dignity are protected?
- 05What actions were taken after the serious safeguarding incident mentioned in the report, and how are people kept safe now?
This was an unannounced comprehensive inspection, followed by a return visit after a serious safeguarding incident, and all five ratings were assessed. This explanation was written from the published report of 26 September 2017 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 Chollacott House Nursing Home
5 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- November 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
Read what inspectors found at Chollacott House Nursing Home →
- September 2017Goodup from Requires improvementSafe: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Chollacott House Nursing Home →
- January 2017Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- July 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- March 2015Requires improvementSafe: InadequateEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- June 2013
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- August 2011
Report published without a new overall rating.
- June 2011
Report published without a new overall rating.
- March 2011
Report published without a new overall rating.
- December 2010
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 20 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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