CQC report explained · a nursing home
What the CQC found at The Chapel House Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected through safeguarding procedures, risk assessments, suitable staffing and safe recruitment. Medicine administration was carried out by trained staff, but records about stock balances and topical medicines were not always accurate or complete.
- Effective?
- Good
- People’s needs, health and nutrition were assessed and monitored, and staff contacted health professionals when needed. Staff received support and training, although training records did not always confirm that mandatory training was up to date.
- Caring?
- Good
- People and relatives described staff as kind, patient and respectful. Staff encouraged independence and involved people and their families in care decisions.
- Responsive?
- Good
- Care plans were mainly detailed and personalised. People were supported to keep in touch with family and friends and to take part in activities, although a new activity team was still being recruited.
- Well-led?
- Requires improvement
- People, relatives and staff gave positive feedback about the management and communication. However, audits did not identify all the issues found during the inspection, and action plans were not always made when problems were identified.
What inspectors found, August 2022
The Chapel House Nursing Home was rated Good overall; inspectors found kind, safe care, but the home’s quality checks needed improvement.
This was the first inspection of this newly registered service. Two inspectors and a person with personal experience of care visited without notice on 5 July 2022. They spoke with two people living at the home, ten relatives and staff, and reviewed care, medicine, recruitment and management records.
Inspectors found that people were safe, treated kindly and supported to make choices. Staffing, safeguarding, infection control, healthcare, food and activities were generally managed well. However, medicine records were not always complete, and staff training records did not always confirm what staff had told inspectors.
The home was rated Good for Safe, Effective, Caring and Responsive. It was rated Requires Improvement for Well-led because its audits did not find every problem and action plans were not always clear. The home had just introduced new audits to improve this.
Kind and respectful care
People and relatives consistently described staff as caring and respectful. Inspectors also observed warm interactions and said staff encouraged independence.
“We observed staff engaging with people during the inspection, in a caring and warm manner.” from the report
Safe staffing
Inspectors found enough safely recruited staff to support people. Relatives said staffing and the quality of staff had improved, although agency staff were still used when needed.
“There were sufficient numbers of safely recruited staff available to support people.” from the report
Clean and prepared for infection risks
The home appeared clean and had infection control procedures, protective equipment and COVID-19 testing arrangements in place. Visits were carried out safely.
“The home appeared clean and well maintained.” from the report
Good communication with families
Relatives said communication had improved with the new manager. The home used meetings, surveys and newsletters to gather views and keep families informed.
“Communication has improved 100% since the new manager arrived.” from the report
Personalised support
Care plans generally reflected people’s needs, choices and preferences. Families were involved when people could not take part in decisions themselves.
“Care plans were mainly detailed and personalised, offering individualised information and reflecting people’s choice and preferences about their care and support.” from the report
Quality checks did not find every problem
needs fixingThe home’s audits did not identify all the issues inspectors found, including problems with medicine records. Action plans did not always say what would be done or who was responsible.
“The audits completed did not highlight all the issues identified during the inspection, such as those regarding medicine records, which were not always completed robustly.” from the report
Training records
minorStaff said they were up to date with mandatory training, but the records did not always support this.
“Training was available, and staff told us they were up to date with their mandatory training, although records did not always support this.” from the report
Mixed views about meals
minorPeople’s nutritional needs were met, but some people and relatives were unhappy with the ready-made meals and wanted more fresh food.
“I'm not sure about the quality of the Appetito meals. He doesn't get fruit or veg.” from the report
- 01How will the new audit system check medicine stock balances and topical medicine records, and who will follow up any errors?
- 02What action plans are now in place for the quality issues found at this inspection?
- 03How do you make sure staff training records are kept up to date and accurately reflect completed training?
- 04What meal choices are available beyond the ready-made meals, including fresh fruit and vegetables?
- 05Has the team of activity coordinators now been recruited, and what regular activities are available?
This was the first inspection of the newly registered service and covered all five key questions, including infection prevention and control. This explanation was written from the published report of 19 August 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, March 2021
The Chapel House Nursing Home had a targeted infection-control inspection; inspectors were assured about COVID-19 safety, but the service was inspected but not rated.
The inspection took place on 22 February 2021. It was announced and focused only on infection prevention and control during the coronavirus pandemic. There were 20 people living in the home, which can accommodate up to 35 people.
Inspectors were assured that the home managed visitors, social distancing, admissions, PPE, testing, cleaning and infection outbreaks appropriately. They found the environment very clean and hygienic. People and staff were taking part in regular COVID-19 testing, and people had individual COVID-19 risk assessments.
The home was inspected but not rated. This means the report does not give an overall quality rating and does not assess areas such as caring, effective care, responsiveness or leadership.
Infection prevention
Inspectors found that cleaning routines had been increased to reduce the risk of infection, and the environment was very clean and hygienic.
“The service had increased the cleaning schedules and routines to reduce the risks of cross infection.” from the report
PPE and testing
Staff were observed wearing the correct PPE. People and staff were also taking part in regular COVID-19 testing.
“People and staff were taking part in regular COVID19 testing.” from the report
Visitor safety
Visitors were screened, had their temperature checked and were given masks, PPE and access to handwashing facilities and hand sanitiser.
“All visitors were asked to complete a health screening form, have their temperature checked and were provided with face masks to wear throughout their visit.” from the report
Family communication
Relatives described receiving regular updates and said visits were pre-booked and well managed.
“We had regular emails and newsletters with updates really regularly” from the report
Inspectors raised no specific concerns in this report.
- 01How are visitors currently screened, and what PPE and handwashing arrangements are in place?
- 02How often are people and staff tested, and how are the results managed?
- 03How often are individual infection-control risk assessments reviewed?
- 04What cleaning routines are currently used to reduce the risk of cross infection?
- 05How would the home manage an infection outbreak and keep relatives informed?
This was a targeted, announced inspection of infection prevention and control only; the service was inspected but not rated. This explanation was written from the published report of 17 March 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 The Chapel House Nursing Home
3 rated inspections over 7 years: the service has held its Good rating throughout.
- August 2022Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at The Chapel House Nursing Home →
- March 2021Inspected but not ratedSafe: Inspected but not rated
Read what inspectors found at The Chapel House Nursing Home →
- December 2017Outstandingup from GoodSafe: GoodEffective: GoodCaring: GoodResponsive: OutstandingWell-led: Outstanding
- November 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2020
Registered with the Care Quality Commission on 14 August 2020.
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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