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Archived: Le Chalet Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 13 July 2018

This announced comprehensive inspection took place on 8, 12 and 20 June 2018 and was unannounced.

Le Chalet is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

Le Chalet is a care home registered to provide accommodation with personal care for up to 12 people in one adapted building. 12 people lived at the service when we visited, with one of the people in hospital.

We had previously carried out an unannounced comprehensive inspection of this service in March 2015. At that inspection we rated the service as good overall. The effective, caring, responsive and well led sections were good. The safe section required improvement due to low numbers of staff on duty. We then carried out a further comprehensive inspection in February 2017. Following that inspection the service was rated as requires improvement overall. The caring section was good. The safe, effective, responsive and well led sections required improvement. Five breaches of regulation were found. We found concerns relating to people’s health, care and welfare. There were not sufficient numbers of suitably qualified, skilled and experienced staff on duty at all times to meet people’s needs. The principles of the Mental Capacity Act (2005) had not been followed. The service had not notified the CQC of incidents as required by law. The provider’s quality assurance systems did not effectively assess and monitor the quality of the service.

Following the inspection in February 2017, the provider submitted a service improvement plan (SIP) to CQC. We then met with the provider and newly appointed manager to discuss the SIP and the timescales required to meet their legal requirements. The local authority Quality Assurance Improvement Team (QAIT) supported and worked with the service up to December 2017 to address the breaches of regulation.

The manager was now the registered manager of the service. A registered manager is a person who has registered with the CQC 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 this comprehensive inspection, we found the provider and registered manager had made improvements to how the service was run. The breaches of regulation had been met. However, there were still further improvements to be made. This related to:

• The management and leadership of the home and the embedding of quality monitoring systems

• The adaptations, fabric and furnishings of the home to make it an environmentally safe and pleasant place for people to live

People and relatives were happy with the care and support provided at Le Chalet. They spoke positively of the management and staff team. There was a relaxed, homely and happy atmosphere at the home.

There were sufficient and suitable numbers of staff on duty to keep people safe and fully meet their needs. The service had recently had two staff members leave. The registered manager had acted quickly and recruited three new members.

Recruitment checks were safely carried out with updated employment records in place. Staff received regular induction, training and supervision. Some of the staff had been historically reluctant to undertake training in the past but the registered manager had addressed this by introducing new training programmes.

People were protected by staff who had been trained in safeguarding people from abuse. They had undertaken training, knew the right action to take and who to inform if abuse had been suspected.

People’s needs were assessed before they came to live at the service. People had personalised and comprehensive care plans in place. They contained all the

Inspection areas



Updated 13 July 2018

The service was safe.

People were supported by sufficient staff on duty to meet their needs fully.

Individual risks to people were in place and managed safely.

Staff were recruited safely to ensure they were able to work with vulnerable people. They were aware of their safeguarding responsibilities and the correct action to take.

People received their medicines safely and on time.

Incidents and accidents were managed safely.

Infection control procedures were in place.


Requires improvement

Updated 13 July 2018

The service was not always effective.

Some areas of the service were not consistently decorated or adapted to a consistent standard. Some areas of the home were in need of maintenance and updating.

Management and staff were adhering to the principles of the Mental Capacity Act.

People�s legal rights were protected because staff knew how to support people if they did not have the mental capacity to make decisions for themselves.

Staff undertook the necessary training to enable them to do their jobs properly. The registered manager was addressing any areas outstanding with individual staff.

People�s health needs were managed through regular contact with community health professionals.

People were encouraged to maintain a balanced diet.



Updated 13 July 2018

The service was caring.

People gave positive feedback about the caring nature of the staff. They said staff treated them with respect and dignity.

Staff were caring, king and spoke pleasantly to people. They knew people well and had developed effective relationships.

Relatives were complimentary of the staff and were able to visit at any time. They were kept up to date with their relative�s wellbeing.



Updated 13 July 2018

The service was responsive.

People had personalised care plans in place which showed their individual choices, preferences and needs.

Staff engaged with people meaningfully and had positive interactions.

Complaints were managed effectively.

An activities programme had been introduced and activities were ongoing and further developing.


Requires improvement

Updated 13 July 2018

The service was not always well-led.

People and relatives were complimentary about the registered manager and their approach at the service.

There were quality monitoring systems in place to review the running of the service and identify any improvements required. The registered manager acknowledged there was still more work to be done.

Policies and procedures and record keeping had been updated.

Notifications had been reported to the Care Quality Commission in accordance with the regulations.

The provider was visible in the service and actively sought the views of people, relatives and staff at the home.

There was no refurbishment plan in place to keep the premises updated and maintained.