CQC report explained · a residential care home
What the CQC found at The Chadwick
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- People generally felt safe, and medicines, incident reporting, pressure care and infection control had improved. However, an untrained hairdresser had helped people move, and some staff were not fully aware of people's emergency evacuation plans.
- Effective?
- Requires improvement
- This question was not assessed in detail during this focused inspection. Its previous rating was used in calculating the overall rating.
- Caring?
- Requires improvement
- This question was not assessed in detail during this focused inspection. Inspectors did observe that people were treated with dignity and respect.
- Responsive?
- Requires improvement
- This question was not assessed in detail during this focused inspection. Inspectors noted that activities were not frequent enough for some people and that some relatives wanted more involvement in care plans.
- Well-led?
- Good
- Management had introduced effective audits, action plans and systems to monitor risks and incidents. Staff and relatives spoke positively about the new registered manager, although some relatives wanted better communication during the pandemic.
What inspectors found, January 2021
Rated Requires Improvement; inspectors found major improvements, but safety and staffing still needed attention.
This was an unannounced focused inspection on 8 and 9 December 2020. Inspectors checked whether the home had fixed problems found at the previous inspection, especially around safety and management. They spoke with people living there, relatives, staff and a health professional, and observed care.
The home had improved since its previous Inadequate rating and was no longer in breach of the regulations checked. Medicines, incident records, care plans, infection control and management checks were much better. People generally said they felt safe and that staff were kind and helpful.
Safety was still rated Requires Improvement. Inspectors found that some staff were not clear about emergency evacuation plans, an untrained hairdresser had helped people move, and some people on the first floor waited a long time for help. Well-led was rated Good, reflecting stronger management, better checks and a more open approach.
Improved management
The new management team had addressed the problems found previously. Audits and action plans were being used across important areas of the home.
“There was a service improvement plan. This included all areas identified as a concern at the last inspection.” from the report
Kind and respectful care
People were treated with dignity and staff had positive relationships with them. Staff knew people well, including their preferences.
“We saw that throughout the visit people were treated with dignity and respect.” from the report
Safer medicines
Medicines records were accurate, medicines were stored securely and audits and staff training were in place.
“A sample of medicines checked showed that the quantities matched the records.” from the report
Better response to incidents
Incidents and unexplained injuries were recorded and investigated. The home had also reduced falls significantly since the previous inspection.
“At the last inspection there were 37 falls in January 2020. In November 2020 falls in the home had reduced to 13.” from the report
Infection control
Inspectors were assured that the home had suitable arrangements for preventing and managing infections, including COVID-19.
“We were assured that the provider was using PPE effectively and safely.” from the report
Emergency evacuation knowledge
needs fixingSome staff were not clear about how to evacuate people who needed help to move or were cared for in bed. Inspectors asked the manager to address this.
“However, some staff were not clear on how they would evacuate someone who may be dependent on staff for mobilising and cared for in bed.” from the report
Untrained person helping with transfers
seriousA hairdresser had helped people to mobilise and transfer, despite not having training or knowledge of their individual risks. The manager said this would be addressed immediately.
“They had not received training and were not aware of people's individual risks.” from the report
Waiting for help
needs fixingSome people on the first floor experienced long waits for assistance. One person said they had waited over an hour for help to use the toilet.
“I had to wait over an hour for help to go to the toilet.” from the report
Limited activities
minorSome people said activities were not frequent enough. Inspectors also found that staff on the first floor could be focused on tasks because of their workload.
“The staff work hard running around, we do not do much here, there are supposed to be people here for activities.” from the report
Communication with relatives
minorSome relatives felt communication during the pandemic could be better, especially when they could not visit. They wanted meetings, letters and more involvement in care plans.
“Some relatives felt that communication during the pandemic could be improved, mainly if they were unable to visit.” from the report
- 01What has been done to make sure every staff member understands each person's personal emergency evacuation plan?
- 02Who is allowed to help residents mobilise or transfer, and how do you check they have the right training?
- 03How often do people on the first floor have to wait for help, especially to use the toilet?
- 04What activities are currently available, and how often are they provided?
- 05How will relatives who cannot use technology be involved in meetings, communication and care plan reviews?
This was a focused inspection of Safe and Well-led; the other ratings were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 15 January 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, December 2020
The Chadwick was rated Inadequate and placed in special measures; inspectors found serious risks from staffing, falls, safeguarding and weak management.
This was an unannounced focused inspection on 20 January and 6 February 2020. Inspectors spoke with people, a relative, staff and managers. They observed care and reviewed care, medicine, incident, falls and management records.
Inspectors found there were not enough staff at some times, especially evenings, nights and weekends. People waited for help and call bells. Risks from falls and pressure ulcers were not managed effectively. Medicines records did not always match the medicines counted, and unexplained injuries were not investigated or reported to safeguarding authorities.
The laundry area created infection control and fire risks. Emergency evacuation drills had not been carried out. Management systems did not identify or deal with repeated problems, and some information given to inspectors was conflicting. The home also failed to notify CQC about an infection outbreak.
The overall rating was Inadequate, and both Safe and Well-led were rated Inadequate. The home was placed in special measures, meaning CQC said it would closely monitor the service and re-inspect to check for significant improvement.
Safeguarding knowledge
Staff understood safeguarding procedures and their responsibility to report and record concerns, although inspectors found that management did not always act on injuries.
“Staff were knowledgeable about safeguarding procedures and their responsibilities to report and record any concerns they may have had.” from the report
Links with health professionals
The home worked with GPs and district nurses when people needed their involvement.
“The service worked in partnership with people's GP and the district nurse team when needed.” from the report
Too few staff and long waits
seriousPeople and staff said there were not enough staff, especially at evenings, nights and weekends. People waited for help with daily needs and for call bells to be answered.
“People told us they often had to wait long periods of time to go to bed in the evenings or for staff to answer their call bells.” from the report
Falls and injuries
seriousInspectors found repeated falls, including one person who fell 24 times and needed hospital checks. The actions taken did not prevent further falls or injuries.
“There were seventy-four falls recorded from 22 November 2019 to 05 February 2020.” from the report
Uninvestigated injuries
seriousMultiple bruises and skin tears were not investigated or reported to safeguarding authorities. There were also no protection plans for people with repeated injuries.
“These unexplained injuries were not investigated or reported to safeguarding authorities.” from the report
Laundry infection and fire risks
needs fixingClean and dirty laundry was not separated. The room was overfilled, with piles of laundry, and inspectors identified increased cross-contamination and fire risks.
“The laundry had not been organised to ensure infection control procedures could be followed.” from the report
Weak management oversight
seriousAudits identified patterns such as night-time falls but did not lead to effective action. Some records and information given to inspectors were conflicting and could not be relied on.
“Inadequate systems and processes to assess, monitor and improve the service meant that lessons failed to be learnt.” from the report
Incomplete notifications and openness
seriousThe home did not notify CQC or the local authority about an infection outbreak. Inspectors also found no evidence that the manager had followed the duty to be open, honest and apologise when things went wrong.
“The registered manager had not been responsive to issues and concerns. They had failed to be open, honest, and apologise to people when things went wrong.” from the report
- 01How many staff are now working on each floor during evenings, nights and weekends, and how do you check that people are not waiting too long for care?
- 02What has changed to prevent falls, particularly at night, and how are individual falls prevention plans reviewed?
- 03How are unexplained bruises, skin tears and other injuries now investigated and reported to safeguarding authorities?
- 04How do you check that medicines records match the medicines in stock and that people receive them as intended?
- 05What action has been taken to separate clean and dirty laundry, practise emergency evacuations and improve management oversight?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried over from the previous comprehensive inspection. This explanation was written from the published report of 10 December 2020 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 The Chadwick
3 rated inspections over a year: the service has held its Requires improvement rating throughout.
- January 2021Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Good
- December 2020Inadequatedown from Requires improvementSafe: InadequateWell-led: Inadequate
- October 2019Requires improvementSafe: Requires improvementWell-led: Requires improvement
- October 2018
Registered with the Care Quality Commission on 26 October 2018.
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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