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Chaxhill Hall Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 26 March 2021

About the service

Chaxhill Hall is a residential care home, providing personal care for 21 people aged 65 and over at the time of the inspection. The service can support up to 36 people with a variety of needs, some of whom live with dementia and/or disability. Chaxhill Hall accommodates 36 people in one adapted building.

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

People had not always been protected from the risk of spread of infection. The service had implemented recommendations made by an infection prevention and control (IPC) specialist during a Covid-19 outbreak at the service in January 2021. However, we found further improvement was needed to ensure IPC risks were managed safely in line with best practice and national guidance.

People’s risks had been assessed and support plans were in place to guide staff in supporting them safely. However, changes to people’s weight and accident reports had not always been acted upon in a timely way, to ensure new risks to people were managed promptly.

People may not always have been protected from abuse as the service had not always done all expected of them in response to safeguarding concerns.

People did not always receive their medicines safely.

People had enough staff suitable staff to support them.

People were not protected by robust systems to monitor and improve the quality and safety of the service. Accurate and complete records had not always been maintained.

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

Rating at last inspection

The last rating for this service was Good (published 22 May 2018).

Why we inspected

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.

We received concerns in relation to people’s safety, people’s medicines and the staff culture. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

We have found evidence that the provider needs to make improvement. Please see the safe and well-led sections of this full report. The overall rating for the service has changed from Good to 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 Chaxhill Hall on our website at


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 monitor the service/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 breaches in relation to safe care and treatment, safeguarding and good governance at this inspection.

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

The provider and registered manager took immediate action to reduce risks to people. However further action was needed to implement and embed the improvements needed.

Follow up

We will request an action plan for 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.

Inspection areas


Requires improvement

Updated 26 March 2021

The service was not always safe.

Details are in our safe findings below.



Updated 26 March 2021



Updated 26 March 2021



Updated 26 March 2021


Requires improvement

Updated 26 March 2021

The service was not always well-led.

Details are in our well-Led findings below.