CQC report explained · a nursing home
What the CQC found at Chorleywood Manor Care 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
- Oxygen therapy was not managed safely, including storage, training and risk assessments. Inspectors also found shortfalls around falls, pressure care, safeguarding knowledge and some waiting times.
- Effective?
- Requires improvement
- Staff supported people's health and followed specialist advice in many cases. However, some staff did not know an up-to-date specialist diet, and staff training and care reviews needed improvement.
- Caring?
- Good
- People were treated with kindness, dignity and respect. Staff spent time with people, supported their choices and encouraged independence.
- Responsive?
- Good
- People had access to activities, trips, events and one-to-one time. Complaints were handled openly, although some care reviews and the handling of missing glasses, hearing aids and dentures needed improvement.
- Well-led?
- Requires improvement
- There was an open and positive culture, and managers acted when inspectors raised concerns. However, audits had not identified several important safety, care planning and staff knowledge problems.
What inspectors found, May 2023
Signature at Chorleywood was rated Requires Improvement; inspectors found kind care but safety, staff knowledge and quality checks were not consistent.
This was the first inspection after a change in the provider's registration. Inspectors visited on 1 March 2023, spoke with people, relatives and staff, and reviewed care records, medicines, recruitment checks, audits and safety records.
The main concern was oxygen therapy. Cylinders were not stored safely, staff had not been trained in oxygen management, and people's risk assessments were not thorough enough. Inspectors also found concerns about falls, pressure care, some diets and safeguarding knowledge. No harm had occurred, but there was a potential risk of harm.
People described staff as kind and respectful. The home was clean, activities were varied, complaints were handled openly and visiting was supported during a COVID-19 outbreak. The overall rating of Requires Improvement means there was limited assurance about safety and that management systems did not always identify or correct important problems.
Kind and respectful care
People were supported in a kind and thoughtful way. Staff respected privacy, dignity, choices and independence.
“People were supported consistently in a kind and thoughtful way by the staff at the home.” from the report
Clean and hygienic home
Inspectors found the home clean and staff followed safe hygiene practices. A recent COVID-19 outbreak was managed safely.
“The home was clean, and staff followed safe hygiene practices.” from the report
Open complaints process
People felt able to raise concerns and saw changes as a result. Complaints were handled openly and lessons were learned where possible.
“These complaints were dealt with in an open way and when possible, lessons were learnt.” from the report
Oxygen safety
seriousOxygen cylinders were not stored safely and staff had not been trained in oxygen management. People's risk assessments did not fully explain the risks.
“Systems had not been established to assess, monitor and mitigate risks to the health, safety and welfare of people using the service.” from the report
Risk assessments and care plans
needs fixingSome risk assessments and care plans were not clear enough. More monitoring was needed for falls and pressure-relieving equipment.
“People's other risk assessments and care plans did not capture people's risks in clear ways to support staff, to know and understand the risks people faced.” from the report
Morning response times
needs fixingSome people waited 15 to 30 minutes for help, particularly during busy mornings. The home was taking steps to recruit more permanent staff.
“Some people told us they felt the mornings were busy times and they had to wait 15 to 20 minutes for support.” from the report
Staff knowledge
needs fixingSome staff lacked up-to-date knowledge about oxygen therapy, falls, safeguarding and a specialist diet for a person at risk of choking.
“We also found some shortfalls in staff practices in relation to falls, people's diets, and safeguarding.” from the report
Quality checks
needs fixingThe provider's audits had not identified several important problems, including oxygen safety, care planning and staff knowledge.
“These issues had not been identified via their own audits with no actions taken to remedy these.” from the report
- 01What changes have been completed to store and manage oxygen safely, and how are these checks recorded now?
- 02What training have all relevant staff completed on oxygen therapy, falls, safeguarding and specialist diets?
- 03How are staffing levels assessed in the mornings, and what is being done to reduce waits for call bells?
- 04How are falls risks and pressure-relieving equipment checked for each person?
- 05How are care plan reviews and quality audits checked to make sure problems are identified and acted on?
This was the first inspection of the newly registered service and covered all five key questions, including infection prevention and control; the previous provider's Good rating was from 2018. This explanation was written from the published report of 17 May 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.
What inspectors found, April 2021
Sunrise of Chorleywood was inspected but not rated; inspectors found strong infection control arrangements during a COVID-19 outbreak.
The inspection took place on 16 March 2021. It was announced and focused on infection prevention and control during the COVID-19 pandemic.
Inspectors found that visitors were screened and given guidance and protective equipment. The home had cleaning routines, infection control zones and arrangements for testing, admissions and managing outbreaks.
The home was inspected but not rated. This was not a full assessment of care quality, so the report does not give an overall Good or Outstanding rating.
Visitor safety
Visitors were screened, given guidance and provided with protective equipment. Visits were arranged to reduce infection risks and allow areas to be cleaned between visits.
“Visitors were welcomed into the entrance hallway by a member of staff, where they were provided with guidance, personal protective equipment (PPE) and health screening was completed.” from the report
Clean environment
Inspectors found the home clean and hygienic, with cleaning carried out methodically during the day. Infection control zoning and isolation arrangements were in place.
“The service was clean and hygienic. Robust cleaning regimes were in place, which were methodically completed throughout the day.” from the report
Support during the pandemic
The home provided activities, newsletters, telephone calls and video calls to help people stay connected and support their wellbeing while normal visits were restricted.
“The service had taken steps to alleviate the negative impact of the pandemic on people.” from the report
Management checks
The provider had pandemic policies, a COVID-19 taskforce and regular checks and infection control audits.
“Management oversight and daily checks, alongside regular infection prevention and control audits were in place.” from the report
Inspectors raised no specific concerns in this report.
- 01How are visitors currently screened and what protective equipment or testing is required?
- 02How often are cleaning, infection control and outbreak management checks carried out now?
- 03What arrangements are in place if a resident is admitted during an infection outbreak?
- 04How would visits and contact with family be managed if visiting restrictions were introduced again?
- 05What current ratings or inspection information is available for caring, effective, responsive and well-led care?
This was an announced targeted inspection of infection prevention and control during the COVID-19 pandemic; it was not a full inspection and the service was inspected but not rated. This explanation was written from the published report of 13 April 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 Chorleywood Manor Care Home
2 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- May 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2021Inspected but not ratedSafe: Inspected but not rated
- August 2018GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2017
Registered with the Care Quality Commission on 1 August 2017.
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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