CQC report explained · a nursing home
What the CQC found at Victoria Chartwell
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People felt safe. Inspectors found safe recruitment, enough staff, suitable risk assessments, good cleanliness and safe medicines management.
- Effective?
- Good
- People had assessments before moving in and received care from trained staff. Inspectors found good support with food, healthcare, communication and personal choices.
- Caring?
- Good
- Staff were polite, caring and respectful. People were involved in decisions about their care, and visitors could come at any time.
- Responsive?
- Good
- Care plans reflected people's needs and preferences. People had access to activities, trips, family contact and support with complaints and end of life care.
- Well-led?
- Requires improvement
- There was no registered manager during the inspection, although a manager had been appointed. Staff were supported by a wider management team, but team meetings were less frequent.
What inspectors found, October 2019
Rated Good overall, but inspectors found inconsistent leadership because there was no registered manager and team meetings had become less regular.
Inspectors made an unannounced visit on 23 July 2019. One inspector spoke with people, a friend, staff and a visiting health professional. They also observed care and checked care, medicine, recruitment and management records.
People were safe and said they felt safe. Inspectors found enough trained staff, safe recruitment, good infection control and safe medicines management. Care was personalised, kind and respectful, with good food, activities and support to keep in touch with family and the community.
The home was rated Good for Safe, Effective, Caring and Responsive. Well-led was rated Requires Improvement. There was no registered manager at the time, although a new manager had been appointed. The overall rating was Good, and this was unchanged from the previous inspection.
Safe staffing and recruitment
Inspectors found enough staff to meet people's needs. Recruitment checks, induction and staff qualifications were also in place.
“The provider ensured there were enough staff to support the people who needed it.” from the report
Kind and respectful care
People were treated kindly and with respect. Staff supported people's dignity, independence and involvement in decisions.
“People were well treated and supported kindly. We saw staff chatting to people in a friendly natural manner.” from the report
Personalised food and activities
The chef knew people's likes, dislikes, allergies and special diets. Activities were adapted so people with different abilities could take part.
“The chef knew people well and had a white board in the kitchen displaying people's likes, dislikes, allergies and special diets.” from the report
Good links with healthcare professionals
Staff worked with outside healthcare services and acted on advice about people's health. People could access visiting professionals such as dentists, opticians and chiropodists.
“The service maintained good relationships with other healthcare professionals and specialist teams, such as pharmacists, opticians and community nurses.” from the report
No registered manager
needs fixingThe home did not have a manager registered with the CQC when inspectors visited. A new manager had been appointed but was still awaiting registration.
“There was no registered manager at the time of the inspection.” from the report
Less regular team meetings
needs fixingBecause there was no registered manager, team meetings were not happening as often as before. This may make it harder for staff to share information consistently.
“Due to the lack of a registered manager these team meetings were not as frequent as they had been in the past.” from the report
- 01Is the manager now registered with the CQC, and who is responsible for the home if the registration is still pending?
- 02How often are staff team meetings held now?
- 03How do you check that staff continue to follow each person's personalised care plan?
- 04How are people's food likes, dislikes, allergies and special diets recorded and reviewed?
- 05How can families raise concerns, and how quickly will the home respond?
This was an unannounced planned inspection covering all five CQC questions, including care, premises and management arrangements. This explanation was written from the published report of 30 October 2019 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, January 2017
Rated Good overall; inspectors found safe, kind and personalised care, but the home needed to improve its management checks and feedback systems.
Inspectors visited the home without warning on 22 November 2016. They spoke with people living there, visitors and staff, observed care, medicines, activities and a mealtime, and reviewed care plans, records, staff files and the home's own audits.
The home was rated Good for safe, effective, caring and responsive care. People said they felt safe and well treated. Inspectors found enough staff, safe recruitment, safe medicines management, detailed care plans, good support with food and health needs, and kind staff who respected people's dignity.
The home was rated Requires Improvement for being well-led. Fluid records did not clearly show people's daily totals, some fire and health and safety checks had not been completed as required, and residents' meetings and formal feedback questionnaires were not used regularly. The overall Good rating means the service met the required standard overall, but its leadership and monitoring were not consistently strong.
People felt safe
People and visitors said they felt safe. Inspectors found enough staff on duty, safe recruitment procedures and prompt responses to call bells.
“People and visitors told us there were enough staff on duty to meet people's needs.” from the report
Kind and respectful care
Staff were friendly, patient and compassionate. People were involved in decisions and their privacy and dignity were protected.
“Staff provided care in a kind, compassionate and sensitive way.” from the report
Personalised support
Care plans included people's histories, preferences, communication, nutrition and mobility needs. Staff knew people well and supported independence where possible.
“The care and support plans were detailed and contained clear instructions about the needs of the individual.” from the report
Safe medicines and health support
Medicines were stored, administered and checked safely. People's health was monitored and advice was sought from healthcare professionals when needed.
“There were appropriate arrangements in place to protect people against the risks associated with the unsafe use and management of medicines.” from the report
Incomplete fluid records
needs fixingFor people at risk of dehydration, staff offered fluids hourly but records did not show the planned 24-hour amount or daily totals. Inspectors said staff understood the care being given, but the records did not fully support it.
“Charts were not totalled to give care staff information on the level of fluids people had had during the day.” from the report
Safety checks were not always completed
needs fixingRegular fire and health and safety checks had not always been completed in line with the provider's own policy and procedure.
“Regular fire and health and safety checks of the building had not been completed in line with the provider's policy and procedure.” from the report
Limited formal feedback
minorResidents' meetings were not held regularly and questionnaires had not been used. This limited people's formal opportunities to influence the service and show whether improvements followed feedback.
“So there were limited opportunities for people to formally give their feedback and for the staff to demonstrate how the service has moved forward and made improvements following feedback gained.” from the report
- 01How do you now record the amount of fluid each person is expected to receive and the total they drink each day?
- 02How often are fire and health and safety checks completed now, and can you show me the latest records?
- 03How often do you hold residents' meetings and use questionnaires or other formal ways to gather feedback?
- 04How do you record and track improvements made as a result of residents' and relatives' feedback?
- 05How are care plans reviewed when a person's health, mobility, nutrition or independence needs change?
This was an unannounced comprehensive inspection covering all five key questions and included observations, conversations and reviews of care, safety, medicines, staffing and management records. This explanation was written from the published report of 24 January 2017 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 Victoria Chartwell
2 rated inspections over 3 years: the service has held its Good rating throughout.
- October 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2016
Registered with the Care Quality Commission on 11 April 2016.
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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