Archived: Chestnut House Nursing Home

Chestnut House Nursing Home is a care home providing personal and nursing care for up to 85 people. At the time of the inspection there were thirteen people living at the service, some of whom were older people living with dementia. People were all accommodated on the ground floor of the home.

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

The provider’s governance systems had not ensured that actions were taken in response to environmental shortfalls. We found no evidence people had been harmed but these shortfalls placed people at risk of harm or injury. They were identified in both the provider’s own audits and our last inspection report. We made a referral to the fire service who arranged a fire safety inspection visit. They identified there were actions that were needed to ensure the fire safety of the service and these works were required to be addressed within two months.

People felt safe and were comfortable and relaxed with staff who supported them. Relatives told us they felt their family members were safe and very well cared for. Throughout the inspection we saw kind and caring interactions between people and staff.

There were enough staff to meet people’s needs and there was a stable staff team who knew people well.

Risks to people were identified and recorded, and staff knew how to respond to these risks in order to keep people safe. Medicines were managed safely and effectively by staff who were trained and competent to do so. A consistent system was not used to record people’s as needed medicines. The provider agreed to ensure this was implemented.

Risks relating to infection prevention and control (IPC), including in relation to the COVID-19 pandemic were assessed and managed. Overall, staff followed recommended IPC practices. Safe visiting was supported.

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.

People benefited from a manager, deputy manager and staff team who promoted a positive culture. They focused on people being treated as individuals and staff had continued to make improvements in the personalised care that people received. Relatives spoke highly of the manager and staff and the communication between them.

Rating at last inspection

The last rating for this service was requires improvement (published 5 August 2021) .The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found the provider remained in breach of one regulation.

The service remains rated requires improvement. This service has been rated inadequate or requires improvement for the last seven consecutive inspections since 2017.

Why we inspected

We undertook this focused inspection as part of our public commitment to rerate services. This was to release capacity in the adult social care sector during the pandemic. This report only covers our findings in relation to the Key Questions Safe, Caring and Well-led.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively. This included checking the provider was meeting COVID-19 vaccination requirements.

We have found evidence that the provider needs to make improvements. Please see the Safe and Well-led sections of this report.

The provider has taken action to mitigate the risks identified and has worked with the fire service to ensure people’s safety.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has remained Requires Improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Chestnut House Nursing Home on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection.

We have identified a repeated breach of regulations in relation to the provider’s oversight and not acting in response to their own and CQC’s previous findings in relation to fire safety issues and hot water temperatures.

We have issued a warning notice that the provider must be compliant with the regulations by 1 April 2022.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Chestnut House Nursing Home is a residential care home providing personal and nursing care up to 85 people. At the time of the inspection there were eight people living at the service, the majority of whom were older people living with dementia.

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

We saw improvements in several areas and three previous breaches had been met in relation to safe care and treatment; staffing and person-centred care. However, continued improvements and the embedding of robust governance systems was still needed.

The provider had introduced new governance checks following the last inspection. These required further time to embed effectively. We found no evidence people had been harmed but we identified systems did not always ensure risks in relation to environmental factors were reduced. For example, the provider and manager’s checks and audits had not identified risks and outstanding actions in relation to hot water temperatures and fire safety issues.

The service had not had a registered manager since August 2019. Following the last inspection, a new manager was appointed. Following this inspection, they submitted an application to be registered with CQC. This is in progress.

People using the service, relatives, staff and professionals expressed their confidence in the new manager and deputy manager. People said there had been significant improvements at the service. Comments included, “Excellent care with the new manager in there; she has really turned it around” and “I am feeling confident with new management arrangements; they are approachable…”

There was improved oversight in the management of risk associated with people’s health needs and conditions. People said they felt safe at the service. Comments included; “I am very well looked after here” and “It’s a happy life here”. Comments from professionals and relatives included, “Excellent care with the new manager in there. I have no worries” and “We have been fairly impressed with them (staff)”.

There were enough suitably skilled and experienced staff on duty to meet the needs of people currently living at the service. People said staff came quickly when needed. Staff were sensitive in the way they responded to people. Their positive approach and presence reinforced a positive, social atmosphere. People looked relaxed and well cared for.

People were protected from the risk of abuse and harm. Staff understood their role to report potential abuse or harm. They had confidence concerns would be acted on by the manager. Medicines were safely managed.

Where mistakes were made, staff were supported to learn lessons and improve practice through further training, support and by sharing information.

Risks relating to infection prevention and control (IPC), including in relation to the COVID-19 pandemic were assessed and managed. Staff followed recommended IPC practices. Safe visiting was supported.

Improvements meant people received personalised care and support. People had increased access to meaningful activities, occupation and stimulation they needed to live fulfilled lives. There was an activities programme for group and individual activities. Care plans were personalised and provided up to date information to staff about how to support people and meet their health care needs.

People and their relatives felt confident to raise any concerns and felt listened to.

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.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update - The last rating for this service was Inadequate (published 07 January 2021). The provider had conditions of registration varied and they were required to submit to the commission a monthly improvement plan based on the audits they completed. At this inspection we found improvements had been made in most areas, however the provider remained in breach of one regulation.

This service has now been rated either requires improvement or inadequate for seven of the eight inspections since 2016.

This service has been in Special Measures since January 2021. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

We undertook this focused inspection to check whether the service was meeting legal requirements. This report only covers our findings in relation to the Key Questions Safe, Responsive and Well-led which contain those requirements.

Our report is based on the findings in those areas at this inspection. The ratings from the previous comprehensive inspection for the Effective and Caring key questions were not looked at on this occasion.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

The overall rating for the service has changed from Inadequate to Requires Improvement. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvement. Please see the safe and well led domains of this report.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Chestnut House Nursing Home on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified a continued breach in relation to regulation 17 Good governance.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan form the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Chestnut House Nursing Home is a residential care home providing personal and nursing care up to 85 people. At the time of the inspection there were 29 people living at the service, the majority of whom were older people living with dementia.

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

The service was not well- led. The providers did not have effective governance systems in place to maintain continuous improvement. The service has not been well-led for five consecutive inspections. This resulted in some people not receiving safe and good quality care. The instability in the management of the service was impacting on the morale of people, relatives and staff.

There were safeguarding systems and procedures in place and staff knew how to report any allegations of abuse. However, some staff told us that some concerns were not responded to robustly and appropriately by line managers. This meant people were potentially at risk because some allegations of abuse were not reported to safeguarding authorities.

Risks were not fully assessed or managed to minimise the risks to some people. This was of concern at previous inspections and had not been fully addressed. Those people particularly at risk were those who needed staff support and monitoring with food and fluids.

People did not receive personalised care and support. People did not have access to the activities, occupation and stimulation they needed to live fulfilled lives. This had been identified as a concern at the previous inspection and people’s emotional well being was still not being met. People’s relationships with their family members were not consistently maintained throughout the pandemic.

There was a small stable core of staff that people and relatives spoke highly of. However, there has continued to be a high turnover of staff. Staff retention and turnover has been an ongoing concern at the service. This has impacted on people as they were supported by new staff who did not know them well. Staff did not have enough time to deliver activities, emotional care and support to people.

We were assured the service were following safe infection prevention and control procedures to keep people safe. The service had ongoing monitoring arrangements to ensure all aspects of infection control followed best practice guidance. However, the audits in place did not cover the current pandemic. The service completed a Covid 19 audit following the inspection visit.

There were improvements in the recruitment of staff or in the management and investigation of complaints.

Staff were caring and sensitively supported people to eat and drink. Overall, relatives told us they were happy with the care their family members received and they were kept up to date about important changes in people’s physical health. There was an increase in positive compliments and on line reviews.

Rating at last inspection and update

The last rating for this service was Requires Improvement (published 29 January 2020). The provider had conditions of registration varied and they were required to submit to the commission a monthly improvement plan based on the audits they completed.

At this inspection enough improvement had not been sustained and the provider was still in breach of regulations. The service is now rated Inadequate.

This service has now been rated either requires improvement or inadequate for seven of the eight inspections since 2016.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 8 August 2019. Seven breaches of legal requirements were found.

We undertook this focused inspection to check whether the service was meeting legal requirements. This report only covers our findings in relation to the Key Questions Safe, Responsive and Well-led which contain those requirements.

Our report is based on the findings in those areas at this inspection. The ratings from the previous comprehensive inspection for the Effective and Caring key questions were not looked at on this occasion.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Chestnut House Nursing Home on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection.

The information about CQC’s regulatory response to the more serious concerns found during the inspection have been added to the report. We imposed additional conditions of registration to ensure compliance with the regulations.

Follow up

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Chestnut House Nursing Home is a residential care home providing personal and nursing care up to 85 people. At the time of the inspection there were 45 people living at the service, the majority of whom were older people living with dementia.

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

The service was not consistently well led. The governance systems in place had not been fully effective in identifying shortfalls in the quality of the service and then improving the quality of the service. The monthly improvement plans submitted to CQC by the registered manager did not reflect the findings and shortfalls found at the inspection. The provider was responsive in providing management cover and support following the departure of the registered manager during the inspection. The provider had identified there had been a deterioration of how well led the service was in the weeks prior to the inspection and had a plan in place to fully assess the service prior to this inspection.

There were safeguarding systems and procedures in place and staff knew how to report any allegations of abuse. However, some people were not always safe from abuse or harm from other people living at the service. Safeguarding measures put in place were not always effective.

Risks to people were not fully assessed or managed to minimise the risks to people. Staff did not have the experience, skills or knowledge to meet the needs of those people living with dementia, mental health needs, autism and complex nursing needs.

There was a very stable nursing staff team and core team of care staff. However, there had been a very a high staff turnover prior to the inspection and there was high use of agency and new staff. There were shortfalls in the information available about the suitability of staff and agency staff.

People’s’ needs were not fully assessed and planned for. Assessments and care plans in place did not fully reflect people’s needs and preferences, they were inaccurate and did not give staff the information and guidance they needed to be able to care for people. People’s life history and experiences were not used to develop personalised care plans. This meant people did not always receive the support they needed to meet their care, welfare and well being needs.

People were not consistently supported to have maximum choice and control of their lives. Staff supported people in the least restrictive way possible and in their best interests but this was not always recorded; overall, the policies and systems in the service supported this practice.

People enjoyed the food, but they had mixed experiences at mealtimes in the way they were supported by staff.

Staff were mostly kind and caring and were fond of people. However, we observed some staff ignored some people who called out or were anxious, upset or difficult to engage with because they were living with dementia or did not communicate verbally. Overall people’s dignity was maintained.

There were group activities provided and people clearly enjoyed these. However, people spent long periods of time without any stimulation or having anything to occupy them. People who spent time in their bedrooms were at risk of social isolation.

People and relatives knew how to complain but complaints were not investigated in line with the provider’s policies. Actions and learning from complaints were not implemented to improve the service people received.

There were significant improvements in the monitoring of people’s fluid intake and the monitoring systems. People’s health needs were well managed, and people were referred to health care professionals appropriately.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was Requires Improvement (published 8 November 2018) and there was an ongoing breach of regulation relating the governance of the service. A condition of registration had been imposed on 5 March 2018 requiring the service to provide CQC with a monthly report on the actions following the service’s audits of people’s care plans and any risks they faced. The registered manager had submitted some monthly action plans to CQC. However, these were not consistently provided and did not meet the condition imposed. At this inspection enough, improvement had not been made and sustained and the provider was still in breach of regulations.

This service has been rated requires improvement or inadequate for the last three consecutive inspections.

Why we inspected

The inspection was prompted in part due to concerns received about the conduct of the registered manager, safeguarding incidents between people and staffing concerns. A decision was made for us to inspect and examine those risks. The inspection was also prompted in part by notification that a person using the service sustained a serious injury. This inspection did not examine the circumstances of the incident and this was reviewed separately.

We have found evidence that the provider needs to make improvements. Please see the safe, effective, caring, responsive and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

The provider took immediate action to mitigate the risks to people and further actions following the inspection.

Enforcement

We have identified breaches of the regulations in relation to safeguarding, safe care and treatment, person centred care, staff recruitment and the leadership and oversight at this inspection.

Please see the action we have told the provider to take at the end of this report.

We have imposed conditions on the provider's registration to ensure compliance with the regulations.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme.

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Chestnut House Nursing home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Chestnut House Nursing accommodates 85 people across three separate units, each of which has separate adapted facilities. One of the units specialises in providing care to people living with dementia. At the time of our inspection the service was providing residential and nursing care to 28 older people some of whom were living with a dementia.

The home had not had a registered manager in post since November 2017. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. An interim manager had been in position since May 2018. A new deputy manager was in position to support the interim manager. Although the interim manager informed us they would be applying to the Care Quality Commission to become the registered manager, concerns remained with regard to the stability of the management of the service.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

At the last inspection in May 2018, we found continued risk in regards people safe care and treatment. We took enforcement action and asked the provider to continue to complete an action plan to show what they would do and by when to improve the key questions Safe, Effective, Caring, Responsive and Well-led to at least a 'good'.

At this inspection although improvements have been made to the key questions, effective, caring and responsive to ‘good’. We found improvement are still required in the key questions, safe and well led. We will therefore continue with the imposed conditions and asked the provider to complete an action plan to show what they would do and by when to improve the key question safe and well led to at least ‘good’.

Quality monitoring systems were not fully effective or robust as they did not monitor whether tasks or actions had been completed. Information was not always shared with regards to risks, and systems and processes for keeping records up to date were not always effective.

Regular checks were made to ensure people were given sufficient to drink and eat. Fluid charts were in place for people at risk of dehydration. Systems to monitor whether people had enough to drink were not always effective, as records were not always maintained.

People were at risk because Personal Emergency Evacuation Plans [PEEP] were not up to date. These are a guide for staff on the most appropriate way to support people to get out of the home safely in the event of an emergency such as a fire or flooding.

People, relatives and professionals told us that they had experienced improvements in the home since the last inspection. Leadership was visible and promoted teamwork. Staff spoke positively about the management and had a clear understanding of their roles and responsibilities.

Lessons had been learnt when things went wrong. Incidents, accidents and safeguarding concerns were seen as a way to improve practice and action had been taken in a timely way when improvements had been identified. People were supported to remain safe. Improvements had been made to risk assessments and incidents and accidents were analysed for themes and trends.

People were protected from avoidable harm as staff understood how to recognise signs of abuse and the actions needed if abuse was suspected. People had person centred risk assessments which identified the individual risks they faced and provided actions for staff to safely manage these. Medicines were administered and managed safely by trained staff.

Overall feedback from people, relatives and staff was that staffing levels had improved. The provider had procedures in place to ensure that suitable staff were recruited. Staff told us they received adequate training, supervision and support.

People were supported by staff who had the correct skills and knowledge to deliver effective care. A new training programme was in place to ensure that staff had the correct skills and knowledge to carry out their roles. New staff undertook shadow shifts with more senior staff to help ensure they were competent and safe to support people. Probationary review meetings were held to check new staff members’ understanding and progress.

People living at Chestnut House had a variety of needs, with some people living with forms of cognitive impairments which could affect their ability to make decisions. Staff had received training in decision making and consent and were working within the legal guidance of the Mental Capacity Act 2005 (MCA). The provider had met their responsibilities with regard to the Deprivation of Liberty Safeguards (DoLS).

People and their relatives spoke positively about the staff supporting them. Improvements had been made in how staff supported people in a way that promoted their privacy and dignity. Staff spoke positively about the people they supported and knew them well.

There were a range of activities on offer for people to take part in. People, their relatives and staff had the opportunity to provide feedback on the service. There was a complaints process in place which relatives told us they understood. The complaints procedure was displayed in the entrance to the home. People and their relatives told us they would be confident to raise a complaint.

Where required, the service was able of provide end of life care to people and received support from specialists to do this.

There were systems in place to ensure people were protected from the risk of the spread of infection. There were a range of checks in place to ensure the environment and equipment in the home was safe. The premises were well maintained and safe. There were plans to improve the exterior of the home to make it safer for people to access.

During our inspection we found a continued breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

You can see what action we told the provider to take at the back of the full version of the report.

Chestnut House is ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service is registered to provide accommodation and residential and nursing care for up to 85 older people over three floors. At the time of our inspection the service was providing residential care to 34 older people some of whom were living with a dementia.

Following our inspection in October 2017 we imposed a condition on their registration. We asked the provider to complete an action plan to show what they would do and by when to improve the key questions Safe, Effective, Caring, Responsive and Well-led to at least a ‘good’.

At the inspection in October 2017 we found people were not safe as people did not consistently receive safe care and treatment, audits and quality assurance systems did not always identify shortfalls in the requirements of the regulations being met.

The provider’s reports had indicated that improvements were being made to address the issues identified at the previous inspection. We found that although action had been taken and some of the regulations were being met, improvements needed to continue to meet further breaches of regulations found at this inspection, which means the service will remain in special measures.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service did not demonstrated to us that improvements have been made and therefore is rated as inadequate overall. This service remains in Special Measures.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures. During this inspection, we identified a number of continued breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The service had not had a registered manager in post since October 2017. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Risks remained to some people as they were not consistently assessed or managed to keep them safe. People particularly at risk were those people living with dementia, and those people with complex health needs and behaviours. People required staff to supervise them to keep them safe. We observed occasions when people were unsupervised. Records identified people were at risk of harm if left unsupervised.

We observed a number of good examples of risks to people being identified, reported, however we also identified instances where risks had not been adequately assessed or mitigated. People and staff were placed at risk of injury when moving and assisting. This was because the wrong equipment was used and staff had not received the correct training.

People and relatives spoke highly about some staff. Some staff were seen to be kind and caring. However not all interactions were seen to ensure people were treated with dignity and respect. Care was seen to be task led, and some care not person centred.

The deployment of staff was ineffective and was not always consistently safe to meet people's needs and protect them from harm. The home had enough staff to meet people’s identified needs although there were occasions during the inspection when staff appeared to be more task focused with this limiting the length of time they could spend talking with people.

The management of medicines was not consistently safe. People may be put at risk through not having their prescribed medicines and medicines administered were not always recorded. We observed there were 12 records missing for people in regards their management of medicines. This meant people may be put at risk through not having their prescribed medicines, and medicines administered were not always recorded.

Staff who administered medicines had received training. We were informed that they had undergone competency assessments in the handling of medicines but only one staff assessment was available for review.

Diabetic care plans were in place and staff were aware of the risk to people in regards their diabetic care. However records gave conflicting information. Although nurses were able to discuss which instruction they needed to follow, they seemed confused to which paperwork was correct. There was a risk that any staff who were not familiar with the care plans or risk to the person may not have been able to follow the care plan.

Some people's care records continued to contain errors and duplicated information preventing them from being person centred. This included the wrong names and wrong information. The records were not easy to find to allow easy access and review. System and process were not in place to ensure accidents and incidents were monitored or measures put in place to reduce the likelihood of reoccurrence.

People were not always treated in a respectful way, and care provided was task led. Staff did not always communicate with people when supporting them with food, drink or moving. People were not always able to receive personal care when required or as their care plan stated.

There were different standards for people living on the ground floor to people living on the first floor. People on the ground floor had rooms that were personalised. People on the first floor did not have their rooms personalised. This did not demonstrate a clear understanding of equality and diversity.

People's rights under the principles of the Mental Capacity Act 2005 were not always upheld. We identified some concerns relating to the five principles of the Mental Capacity Act 2005 (MCA). People had moved rooms, although this had been discussed with the relevant health professionals and family, records were not kept that demonstrated how and who made the decision in the person best interest.

People’s nutritional needs were taken into consideration. Some people were at risk of weight loss, measures were in place to monitor people weight on a regular basis. However people were observed being served lukewarm food. The heated trolley was only able to be heated in the kitchen. Therefore once it left the kitchen food had no way of staying hot.

The systems in place to assess and monitor the quality and safety of the service had not been effective in identifying some of the concerns we found during this inspection. Although concerns had been raised during the previous inspection, inadequate efforts had been made to improve in those areas.

People did not have access to sufficient opportunities to leave the service, to socialise or take part in activities that met their individual needs and interests. Creative measures had not been taken to ensure people had access to activities which met their preferences or their needs.

There was a complaints process in place which relatives told us they understood. The complaints procedure was displayed in the entrance to the home. People and their relatives told us they would be confident to raise and complaint.

Where required the service was capable of providing end of life care to people and received support from specialist to do this.

The premises and the equipment were well maintained. Regular checks were undertaken in relation to the environment, maintenance and the safety of equipment. Good infection control practices were in use and there were specific infection control measures used in the kitchens and the laundry rooms.

We found multiple breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

The service is registered to provide accommodation and residential and nursing care for up to 85 older people. At the time of our inspection the service was providing residential care to 48 older people some of whom were living with a dementia.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At the last inspection, the service was rated Good overall. At this inspection we found seven breaches of the regulations.

The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of Inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Prior to our inspection, we received information of concern about staffing levels in the home and standards of care.

People did not consistently receive safe care and treatment. Allegations of abuse were not always reported to the safeguarding authority as required. This was because the adult safeguarding procedures in place were not followed. This potentially placed people at risk of further harm or abuse.

Risks to some people were not consistently assessed or managed to keep them safe. People particularly at risk were those people living with dementia, those with specialist diets and those people with complex mental health needs and behaviours.

The deployment of staff was ineffective and was not always consistently safe to meet people’s needs and protect them from harm.

The management of medicines was not consistently safe as people did not always shave access to their prescribed medicines. There were gaps in the records of the administration of medicines and protocols for “when required” lacked detail of actions that staff needed to follow before administration.

People’s rights were not protected because staff had not acted in accordance with the Mental Capacity Act 2005 (MCA). Conditions of authorisations to deprive people of their liberty were not being met.

Staff did not receive training and support to carry out all aspects of their roles. Staff did not receive training to support people living with dementia that required positive behaviour support.

Improvements were required to support people to drink safely and to monitor people at risk of poor hydration.

People were supported to access healthcare services when needed.

People and relatives spoke highly about some staff. Some staff spent time with some people and treated people with kindness and compassion.

However not all people were treated with dignity, respect and care at times was task led. Some care provided was not person centred.

People did not always receive care that met their needs and preferences.

Some people took part in social activities or were supported by staff to reduce social isolation.

Concerns and complaints were not always responded to identify how the service could be improved.

The provider did not maintain accurate, complete and contemporaneous records. People's daily monitoring charts were incomplete and included gaps and omissions.

There was not an open and transparent culture in the home. Audits and quality assurance systems did not always identify shortfalls in the requirements of the regulations being met.

During our inspection we found a number breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the registered providers to take at the back of the full version of the report. Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

Chestnut House is a purpose built care home accommodating older people. The home is registered to provide accommodation for 85 people who require nursing or personal care. At the time of the inspection there were 78 people living at the home. It comprises of two main areas; people with nursing care needs are resident on the ground floor; people with enduring mental health needs live on the two upper floors. The second floor is allocated for the care of females only.

There was a registered manager in place who had been in post for a number of years. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The home had safe systems in place to protect people from the risks they faced. People’s individual care records evidenced that risks were recorded and action had been taken in accordance with the providers policies to minimise these risks.

Medicines were managed in accordance with best practice guidance. Medicines were stored, administered and recorded safely. People were supported to access external health professionals, when required, to maintain their health and wellbeing.

We observed that staff had developed an empathetic approach to the people they supported. We saw that people appeared comfortable in the company of staff. Staff knew people well and were able to tell us about the people they supported including their history, family, likes and dislikes. This demonstrated staff knew people well and listened to their preferences.

People were offered a varied choice of meals, where staff were concerned that people may be at risk of dehydration or malnutrition the provider had systems in place to address these risks.

People told us and we observed that people were supported by sufficient numbers of staff who had a clear knowledge and understanding of their individual support needs. People living at Chestnut House told us they were happy with the care and support provided. These comments were supported by the relatives we spoke with.

People were supported by staff who had received training with regards to their needs. Staff told us they were supported by the provider to train in areas that they wished to.

People’s social and emotional needs were met by a group of staff employed to provide activities and social stimulation. People told us there was plenty to do if you wished too. The home also enjoyed the support of volunteers and members of the wider community who supported fund raising and the provision of activities.

Some people who lived at the home were able to make decisions about what care or treatment they received. Where people lacked capacity to make some decisions, the staff were clear about their responsibilities to follow the principles of the Mental Capacity Act (MCA) when making decisions for people in their best interests.

The service was responsive to people’s individual needs. Care and support was personalised to each person which ensured they were able to make choices about their day to day lives.

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Chestnut House on our website at www.cqc.org.uk

Chestnut House is registered to provide accommodation and nursing or personal care for up to 85 people. At the time of the inspection there were 75 people living at the home. It comprises of two main areas; people with nursing care needs are resident on the ground floor; people with enduring mental health needs live on the two upper floors. The second floor is allocated for the care of females only.

The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

There were not always clear risk assessments in place and although regular checks on people were made, areas of possible risk were not always identified.

Some people were at risk of developing sore skin, issues were highlighted promptly and treatment was appropriate and effective, however staff did not consistently record when people were being supported to move which meant that it was not clear that people were being protected from their skin becoming sore.

Audits were not always effective. There were some gaps in quality assurance audits which meant that some audits had not been completed as frequently as planned and there were some gaps in recording which had not been picked up by audits which had been completed.

People were supported by staff who were caring in their approach, however some language used by staff to describe people was not respectful.

There were systems in place to ensure people had enough to eat and drink. Where people needed particular diets or support to eat and drink safely this was in place.

People were protected from harm because staff knew how to identify and respond to abuse and said they would be confident to do so.

There were enough staff to support people and we observed that staff used equipment safely and reassured people when they were assisting them to move.

People were supported to received their medicines as prescribed by staff who had received training and undertaken competencies to manage medicines safely.

People and staff spoke positively about the management of the home and told us that the registered manager was approachable. Staff gave us examples of ideas and suggestions they had made which had been listened to and acted upon.

People and relatives, staff and other professionals were asked for their views twice yearly using a survey and there were forms in the reception area to encourage people to make suggestions about the service.

Staff were clear and confident about their roles and there were systems in place to ensure that information was handed over at each shift and that team leaders updated management daily.

Chestnut House is a purpose built care home accommodating older people. The home is registered to provide accommodation for 85 people who require nursing or personal care. At the time of the inspection there were 78 people living at the home. It comprises of two main areas; people with nursing care needs are resident on the ground floor; people with enduring mental health needs live on the two upper floors. The second floor is allocated for the care of females only.

There was a registered manager in place who had been in post for a number of years. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The provider was meeting the some of the requirements of the Mental Capacity Act 2005 but further improvements could be made in the assessments of people’s mental capacity. People’s views or people important to them did not consistently have their comments recorded. Not all best interest decisions were complete. Staff understood some of the concepts of the Act, such as allowing people to make decisions for themselves. The staffs understanding of the act was consummate to their role

The risks people took were not consistently managed. Although risk assessment and plans had been put in place to minimise these risks changes in observational systems had had not considered these risk assessments and had put people at risk of harm. The registered manager was made aware of this and took steps to reintroduce the recordings of observations which had previously been in place instead of just visual observations without recordings being undertaken.

The provider had systems in place to ensure the quality of the service was regularly reviewed and improvements made but some of these processes need improvement. Medicines audits needed to be more robust to acknowledge all of the dispensing carried out by staff. Guidance to staff in relation to managing difficult behaviours was ambiguous and not fully understood by staff meaning that people and staff could be put at risk of harm.

The management at the home had developed an open culture through regular meetings with the people living there and people important to them. The staff told us they felt supported by the management and that their opinions were valued.

The staff knew people’s needs well but the care records did not always reflect their comments. One person told us, “I don’t want for too much, staff know what I need and how to help me, I don’t have any complaints”. Visiting relatives told us about how they considered their relatives were well cared for and how staff ensures their (relative) needs were met.

The staff demonstrated a caring and compassionate approach to people living at the home. People were offered choices at mealtimes such as where to sit and what to eat. The provider had a system to offer a choice of food during mealtimes.

People told us there were enough staff to meet their needs and our observations confirmed this, however, how they were deployed at key times of the day needed to be reconsidered in order to meet people’s needs.

The staff told us they worked well as a team and enjoyed working at the home. The home offered many activities such as a pub night in a purpose built bar area at the home. The provider was also using many initiatives to work with people with dementia such as ‘Namaste’ principles in use at the home. (Namaste Care is a program developed to offer meaningful activities to people living with dementia.)

The home was awarded accreditation with the Gold Standards Framework in Care Homes and achieved a beacon status. This is a nationally recognised award which recognises the high quality of care provided for people at the end of their life.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we asked the provider to take at the back of the report.

People were given the right medication at the right times. The provider had systems in place to ensure that medication was administered safely.

The home provided a safe and adequately maintained environment. Where some of the furniture was showing signs of wear the provider had an action plan in place to update these.

The records used by the home to ensure that people's needs were assessed and met were accurate and updated where required.