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Chandos Lodge Nursing Home Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 18 April 2020

About the service

Chandos Lodge Nursing Home is a care home providing personal and nursing care to older people and people living with dementia. The home can accommodate up to 31 people in one adapted building. At the time of our inspection 28 people were living at the home.

People’s experience of using this service and what we found

People were not always protected from risks around unsafe recruitment. Records were not always held or fully completed in relation to staff’s prior conduct, suitability or employment history. Staffing levels were based on the number of people rather than their level of need. We received mixed feedback from people about staffing levels, although they did not feel this impacted negatively on their quality of life. We have made a recommendation about the calculation of staffing levels.

Legionella risks were not managed effectively; health and safety checks were not fully implemented and risk assessment actions had not been followed-up. We have made a recommendation about this. Systems were implemented successfully for other health and safety risks such as fire evacuation. People’s specific risks were identified and mitigated. Medicines were stored safely and administered to people as prescribed. Staff followed infection control procedures to reduce risk to people.

Management were not familiar with all regulatory requirements such as recruitment or legionella requirements. These areas had not been checked or identified as requiring improvement through the provider’s own audits. Quality assurance audits had been implemented and covered people’s care needs and other areas of risk. People, relatives and staff were positive about the leadership of the service and the standard of care provided. Management made sure that the Commission was notified of events in line with requirements.

Scheduled activities did not always meet people’s individual preferences to provide meaningful engagement. We have made a recommendation about this. People’s needs and preferences were assessed and documented, and staff knew people well. A complaints procedure was implemented to make sure concerns were investigated and outcomes were communicated. People’s end of life wishes were explored and recorded in care plans.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Staff were respectful of people’s rights and people felt they were treated well. Records showed that people and their relatives were involved in reviews of people’s needs and planning care. Staff demonstrated they valued and protected people’s privacy and dignity.

For more details, please see the full report which is on the CQC website at

Rating at last inspection (and update)

The last rating for this service was requires improvement (published 8 April 2019) and there were three breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made and the provider was still in breach of regulations.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.


We have identified breaches in relation to staff recruitment checks, understanding of regulatory requirements and ineffective monitoring systems at this inspection.

We are considering what action to take in light of the Covid-19 emergency. This is to make sure the action we take is proportionate, considers current risks to people's safety, as well as the potential impact of our actions upon people, care providers, registered managers and the wider system during this time.

Follow up

We will meet with the provider following this report being published to discuss how they will make chang

Inspection areas


Requires improvement

Updated 18 April 2020

The service was not always safe.

Details are in our safe findings below.



Updated 18 April 2020

The service was effective.

Details are in our effective findings below.



Updated 18 April 2020

The service was caring.

Details are in our caring findings below.


Requires improvement

Updated 18 April 2020

The service was not always responsive.

Details are in our responsive findings below.


Requires improvement

Updated 18 April 2020

The service was not always well-led.

Details are in our well-led findings below.