CQC report explained · a nursing home
What the CQC found at Chorlton Place Nursing 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 2024
Rated Requires Improvement; inspectors found risks in medicines, staffing, dignity and management systems.
This was an unannounced inspection on 23 and 31 January 2024. Inspectors spoke with people, relatives, staff and visiting professionals. They observed care and reviewed care records, staff recruitment files, medicines records and management documents.
The home was not always safe. Medicines were sometimes given at the wrong time, records were unreliable and some medicines were not stored safely. Staff did not always follow infection control guidance, and people said there were not always enough staff to meet their needs promptly.
Inspectors also found that people were not always treated with dignity and respect. New electronic care plans lacked some of the detail in the old paper records. The home’s checks did not identify or address important problems quickly enough.
The overall rating is Requires Improvement, down from Good at the previous inspection. Effective and Responsive were rated Good. Safe, Caring and Well-led were rated Requires Improvement.
Health support
Staff worked with health and social care professionals and referred people for help when needed. Professionals said staff noticed deterioration and knew how to escalate concerns.
“Staff notice deterioration in people and know how to escalate.” from the report
Training and induction
Staff completed a range of training and a comprehensive induction programme. People said that well-trained carers knew what they were doing.
“The good carers care and know what they are doing and are well trained.” from the report
Food and choice
People generally had enough food and drink and could choose what they wanted to eat. Staff supported people during meals and showed meal options when needed.
“The food is good and you can have a choice.” from the report
Raising concerns
People and families knew how to raise concerns and could ask to speak with the manager. The home had complaints policies and procedures.
“If I want to speak to the manager, I ask the staff to arrange a meeting which they do.” from the report
Medicines
seriousSome medicines were given at the wrong time, including insulin. Records for medicines, creams and thickened fluids were not always accurate, and some medicines were not stored safely.
“Medicines were not always managed consistently, and this meant that medicines were not always managed safely which placed people's health at risk of harm.” from the report
Staffing and response times
needs fixingPeople did not always feel there were enough staff, and inspectors saw communal areas left without staff for lengthy periods. Call bells and requests for help were not always answered promptly.
“We observed staff were not always visible within communal areas to attend to people's needs in a timely way” from the report
Dignity and respect
seriousSome people said staff spoke abruptly or did things without warning. People’s personal preferences were not always followed, and some had to ask repeatedly for help to use the toilet.
“The provider had failed to ensure that service users are treated with dignity and respect.” from the report
Care records
needs fixingThe new electronic care plans did not always contain the personalised detail found in the previous paper records. They did not always explain people’s needs, preferences or how to support independence.
“The new care plans lacked the personalised detail which had been in the paper records.” from the report
Infection control
seriousStaff did not always remove or use protective equipment correctly or manage clinical waste safely. Some damaged surfaces also made effective cleaning harder.
“We saw a staff member using a wheelchair to transport clinical waste and then use the same wheelchair to transfer a person.” from the report
Quality checks
seriousThe home’s monitoring systems did not identify or address several problems, including medicines and infection control issues. There were no action plans for some identified concerns.
“The provider's quality assurance systems failed to identify and/or address in a timely manner some of the shortfalls we found at the inspection” from the report
- 01What has changed to make sure medicines are given at the correct time, with personalised guidance and accurate records?
- 02How many staff are expected to be on duty during the day and night, and how do you respond when call bells or toilet requests are delayed?
- 03How are staff now recording people’s preferences, dignity needs and independence in the electronic care plans?
- 04What actions have been taken to improve infection control, including the handling of clinical waste and the condition of damaged surfaces?
- 05How will you show that quality checks are identifying problems and that action plans are completed?
This was an unannounced inspection that assessed all five CQC questions, and the report says the previous Good rating for each question changed or remained as stated in this inspection. This explanation was written from the published report of 16 March 2024 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, February 2022
Chorlton Place Nursing Home is rated Good after improvements, with safe and caring support but some medicines record anomalies.
This was an unannounced focused inspection. Two inspectors and an Expert by Experience visited from 18 to 20 January 2022. They observed care, spoke with people, relatives and staff, and checked care, medicines, staffing and management records.
The home was rated Good overall. Safe, Responsive and Well-led were rated Good. Inspectors found better risk assessments, enough staff, improved care plans, safe medicines procedures and positive relationships between people and staff.
There was one medicines record issue. The electronic system did not always calculate medicine stocks correctly. Inspectors were satisfied that nobody missed medicines and that the provider had taken corrective action.
The previous rating was Requires Improvement, with breaches relating to management systems and staffing. Inspectors found enough improvement had been made, so the home was no longer in breach. Effective and Caring were not inspected during this visit, so their previous ratings were used in calculating the overall rating.
Personalised risk planning
Risk assessments were detailed and reflected people's individual circumstances and care needs.
“There were comprehensive, personalised risk assessments which reflected individual circumstances.” from the report
Staffing improved
The home had increased night staffing since the previous inspection. Inspectors found enough staff to meet people's needs safely and promptly.
“At this inspection we found the provider increased the care workers from two to three along with a nurse on duty.” from the report
Family communication
Relatives described communication with the home positively, including support to stay in contact during visiting restrictions.
“Communication is excellent. The manager always gets back to me.” from the report
Clean environment
The home was clean and hygienic, with enhanced cleaning schedules observed during the inspection.
“The home was clean and hygienic, with enhanced cleaning schedules in place which we observed during the inspection.” from the report
Electronic medicines stock records
needs fixingThe electronic medicines system did not always calculate medicine stocks correctly. Inspectors found no evidence that anyone missed medicines, and the provider said it had taken corrective action.
“We identified some anomalies with the eMAR system when calculating the medicines stocks.” from the report
Remaining end-of-life training
minorSome staff had received end-of-life training through links with Macmillan, but further training for the rest of the staff team was still due.
“Future training was due to take place for the remaining staff team.” from the report
- 01What corrective action was taken to fix the electronic medicines stock calculations, and how are these records checked now?
- 02How many staff are on duty overnight on each floor, and how is this matched to residents' needs?
- 03Has the remaining end-of-life training now been completed, and which staff have received it?
- 04How will you keep us informed about changes in visiting arrangements or infection control procedures?
- 05How are families' feedback and complaints recorded and used to make improvements?
This was a focused follow-up inspection of Safe, Responsive and Well-led; Effective and Caring were not inspected and their previous ratings were used to calculate the overall rating. This explanation was written from the published report of 4 February 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.
Every inspection of Chorlton Place Nursing Home
6 rated inspections over 9 years: the service has slipped, from Good to Requires improvement.
- March 2024Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- February 2022Goodup from Requires improvementSafe: GoodResponsive: GoodWell-led: Good
- March 2021Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- January 2020Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- June 2017Goodstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2014
Report published without a new overall rating.
- June 2014
Report published without a new overall rating.
- April 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- October 2011
Registered with the Care Quality Commission on 31 October 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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