Cholwell House Nursing Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of the legal regulations relating to safe care and treatment.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Accidents and incidents were reported, and investigations took place to identify what went wrong. Staff confirmed their awareness of the incident reporting process. One staff member said, “I would tell my senior nurse and the clinical lead. And the manager, then there will be an investigation. We would have a review and work out what went wrong to put it right.”

Lessons learnt from accidents and incidents were discussed in team meetings and actions needed to reduce risks following incidents were shared with the team.Following a review of incidents the service has introduced training to support staff in assisting people during times of distress.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. Systems were in place to ensure a good transition into the service. Leaders confirmed how people and relatives were involved in their needs assessment during the pre-assessment process to ensure the service could meet the person’s needs. One relative we spoke with said, “I went through [relative’s] medication [with the service] when he moved in, and I filled out an ‘all about me sheet’ before he moved in.”

Leaders told us about processes in place for management oversight of people’s needs and any changes to people’s needs. For example, daily professional meetings took place to discuss any concerns about people’s needs.

The service worked well with other healthcare professionals. Staff told us how they referred people for specialist advice and support such as speech and language therapy (SALT), or the tissue viability nurse. We saw records of these referrals.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Staff were trained in safeguarding and knew what to do if they had any concerns about the wellbeing of any of the people living in the service. One staff member confirmed they had raised a safeguarding concern. The staff member said, “I am fine [with raising safeguarding concerns] I would do this anytime of the day.”

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Information in some people’s care plans was not always clear, such as information about how to support a person in the event of an epileptic seizure, and how to provide appropriate support when a person is experiencing distress. When this was highlighted, the provider took action to update the person's seizure management plan.

When pressure-relieving equipment was in use, this was documented in the care plan. However, we checked air mattresses with a member of staff during our onsite visit, it was identified that, of the 5-air mattress we looked at, 4 were set incorrectly for the person using them. This was despite records showing staff had carried out mattress checks. The settings on all of the mattresses were immediately reviewed and the issue rectified during the inspection. .

It was not clear how staff monitored repositioning changes for people at risk of pressure injuries. For example, we looked at the care plan for one person where the guidance was for staff to support the person to change position every 2 hours. Position change records we looked at over a 3-week period for the same person did not reflect the care plan guidance. We spoke with leaders about this. Leaders confirmed there had been an issue with the electronic recording system and they assured us the person had been repositioned. However, the provider had not picked this issue up in their own audits which meant there was a risk people were not being repositioned in line with their care plans.

However, people had been appropriately assessed for risks such as skin damage, falls and choking, and when risks were identified care plans provided information for staff on how to reduce these risks. Some people were at risk of malnutrition or dehydration. Food and fluid intake records we looked at showed people were supported to have enough to eat and drink. Staff told us the electronic care planning system flagged when someone had not had enough to drink. One staff member said, “The system shows us when fluid intake is low. If I see it is low intake, I tell the care staff to encourage people to drink. I check it three times a day.” Care plans for people who were at risk of falls were detailed and provided information for staff on how to promote people’s independence whilst also reducing the risk of falls.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

During our onsite visit, it was identified there were trip risks in people’s bedrooms with trailing wires and an unsecured room which, due to the service undergoing some refurbishments, contained builders’ tools and electrical wiring which could have posed a risk to people. This was immediately rectified by the service at the time of the inspection and evidence sent to CQC to demonstrate this had happened.

Audits took place in the home regularly to check the safety of the service and improve the quality of the environment taking into account the needs of people living with dementia, however they had not picked up the concerns identified during the onsite inspection.

However, the service ensured equipment was regularly checked and maintained to ensure it was safe to use and the provider worked in partnership with the fire service to ensure the premises were safe and risks were appropriately managed.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Systems were in place to ensure staff were safely recruited, for example to check staff were of good character. Staff completed training appropriate to their role and received supervision to discuss their role and training requirements.

Systems were in place to ensure there were enough staff to meet people’s needs. Most relatives said there were enough staff in the service. One relative said, “we have no complaints on staffing levels.” Another relative told us, “There are always enough staff working.” However, another relative felt there were less staff at the weekends, and one relative said, “If I need someone, I can find someone, but I sometimes feel the ratio isn’t enough.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service was observed to be clean and overall, well-maintained. Staff had completed infection prevention and control training and followed safe infection prevention and control practices.Staff confirmed their awareness of the systems in place to maintain good infection control.

Clinical waste and soiled laundry were managed and disposed of in accordance with best practice guidelines.

Audits completed by the management team identified areas for improvement and actions were taken to address these. People and relatives did not raise any concerns about infection control standards in the home.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Policies and procedures were in place relating to medicines, however in some cases these were not being followed. A system of medicines audits was in place; however, audits were not undertaken at consistent intervals. This meant issues with medicines were not always identified in a timely way. Audits had not identified the issues we observed onsite. For example, there were some gaps on the Medicines Administration Records (MAR charts), we could not be assured these medicines had been administered. Additionally, there were no details on appropriate seizure management for a person at the service with a diagnosis of epilepsy. However, staff were able to tell us how they would clinically manage this situation. The provider took action to update the person's seizure management plan. It was also identified that prescribed topical creams were not being stored safely and securely in line with national guidance. This put people at risk of harm as people may have been able to access them. The provider took prompt action to ensure safe storage of topical creams following the onsite inspection.

However, we observed medicines were given to patients in a person-centred and caring way. Staff completed mandatory medicines management training and annual assessments were completed to ensure they remained competent. Some care plans included detailed information to assist staff with medicine administration, monitoring for side effects and supporting people with long-term health conditions such as diabetes and Parkinson’s disease.

The provider had identified shortfalls in the oversight of medicines prescribed to the home by the GP and raised these concerns with the GP surgery. In response, the GP practice has since appointed a pharmacist to strengthen medicines optimisation and ensure safe prescribing practices, in line with NICE and CQC guidance. However, at the time of the inspection it was too early to assess the impact of this intervention on the safety and effectiveness of medicines management within the service.