CQC report explained · a nursing home
What the CQC found at Cholwell House Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, May 2021
Inspected but not rated; inspectors were assured that infection prevention measures were in place, with one issue affecting the visitor route.
This was an announced, targeted inspection on 17 March 2021. It focused on infection prevention and control during the COVID-19 pandemic.
Inspectors were assured about the use of personal protective equipment, testing, social distancing, cleaning, admissions and managing infection outbreaks. They found the home clean and found that staff had received relevant COVID-19 training.
The home had a process for visits, including booking, testing, temperature checks and protective equipment. However, building work meant visitors had to walk through the home to reach the visiting area during the inspection.
The service was inspected but not rated. This was not a full inspection of all five areas of care.
PPE and staff training
Staff used suitable PPE and had completed training on COVID-19 symptoms, management and putting on and removing PPE.
“All staff used the appropriate Personal Protective Equipment (PPE) in line with current government guidance.” from the report
Clean surroundings
Inspectors found the home clean, with cleaning carried out regularly during the day.
“We found the home to be clean with regular cleaning taking place throughout the day.” from the report
Visiting arrangements
Families could book visits and use testing, temperature checks, PPE and protective screens. Outdoor seating and a separate, ventilated visiting area were also available.
“Families were able to book a visiting slot and followed a process which included a temperature check and the wearing of PPE.” from the report
Contact with families
People could use tablets for video calls, and the home had installed an extra telephone line for families.
“The provider had installed an additional telephone line, so families had a dedicated line to speak with their loved ones.” from the report
Visitor route during building work
minorBuilding work meant visitors had to walk through the home to reach the visiting area during the inspection. Ask whether this has now been resolved.
“However, at the time of our visit, external work was being done which meant visitors had to walk through to the visiting area.” from the report
- 01Has the external work finished, so visitors can reach the visiting area without walking through the home?
- 02Are visitors still required to book a slot, take a lateral flow test and wear PPE?
- 03How are staff kept up to date with changes to infection prevention guidance?
- 04How often are communal areas cleaned during the day?
- 05How can residents keep in touch with family by telephone or video call?
This was a targeted inspection of infection prevention and control during the COVID-19 pandemic; it did not provide ratings for the other care areas. This explanation was written from the published report of 1 May 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.
What inspectors found, July 2018
Rated Good; inspectors found safe, kind and personalised care, but some medicines and care records needed improvement.
This was a comprehensive inspection over two days. The first day was unannounced. Inspectors spoke with people living in the home, relatives, staff and healthcare professionals. They reviewed care records, medicines, staffing, training, complaints and quality checks.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe care, kind staff and care tailored to people's needs. People were supported with food, drink, healthcare, activities and end-of-life wishes.
There were some shortfalls. Some medicines records were incomplete or unclear. Some emergency evacuation plans and daily care records were out of date or not fully completed. Inspectors also saw one occasion when a person's dignity was not respected.
The overall Good rating stayed the same as at the previous inspection. The report says there was no evidence of serious risks or concerns, but it asked the provider to review medicine audits and monitoring.
Enough staff
People and relatives said staffing was sufficient. Inspectors found staff supported people in a relaxed and unhurried way.
“Everyone we spoke with confirmed people were supported by sufficient numbers of staff to meet their needs in a relaxed and unhurried manner.” from the report
Kind relationships
People appeared relaxed with staff. Inspectors saw staff being attentive and caring, and found strong relationships with people and relatives.
“From our observations, we could see that people were relaxed in the presence of staff and appeared to be happy.” from the report
Personalised care
Care plans reflected people's health needs, preferences and interests. People and relatives were involved in planning and reviews.
“People received care that was responsive to their needs and personalised to their wishes and preferences.” from the report
Activities and community links
The home offered activities linked to people's hobbies and preferences. It also had links with schools, choirs and other local visitors.
“Activities have to be meaningful, so we respond to what people want to do” from the report
Leadership and monitoring
Inspectors found committed leaders, high staff morale and regular checks on areas such as medicines, safeguarding and dignity.
“There were quality assurance systems in place to monitor health and safety and plan on-going improvements.” from the report
Incomplete medicines records
needs fixingSome medicine administration entries had not been checked by a second member of staff. Inspectors also found gaps or unclear directions for creams and missing protocols for some as-needed medicines.
“However, some entries had not been double signed.” from the report
Covert medicines process
seriousOne person receiving medicines without their knowledge did not have the required capacity assessment and legal safeguards in place at the time of inspection.
“Although people who lacked capacity had capacity assessments and DoLS regarding living in the home, these were not in place for one person who was given medicines covertly.” from the report
Out-of-date emergency plans
needs fixingSome personal emergency evacuation plans were out of date. The registered manager said they would be revised.
“Although everyone living in the home had a Personal Emergency Evacuation Plan (PEEP) some of these were out of date.” from the report
Care records not always complete
needs fixingDaily records did not always show that required care had been given, including oral and dental care. The manager knew about the record-keeping problem and had a plan to address it.
“Daily records were not always fully maintained, such as recording oral/dental care where people required support with this.” from the report
One dignity concern
needs fixingStaff were usually respectful and caring, but inspectors observed one occasion when a person's dignity was not respected.
“Although staff were highly motivated to offer care that was kind and promoted people's dignity, we observed one occasion when one person's dignity was not respected.” from the report
- 01What changes have you made to medicine administration records, including double-signing and recording creams?
- 02How do you make sure as-needed medicines have clear protocols and are given at the right time?
- 03How do you check that covert medicines have the required capacity assessments, best-interest decisions and legal safeguards?
- 04Have all personal emergency evacuation plans been updated, and how often are they reviewed?
- 05How do you make sure daily records, including oral and dental care, are completed and checked?
This was a comprehensive inspection covering all five key questions; the overall Good rating remained unchanged from the previous inspection. This explanation was written from the published report of 27 July 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.
Every inspection of Cholwell House Nursing Home
2 rated inspections over 3 years: the service has held its Good rating throughout.
- May 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- July 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Outstanding
- December 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- August 2011
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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