You are here

The Chimes Residential Home Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 7 December 2019

About the service

The Chimes Residential Home provides accommodation with personal care for up to 44 people. People who

use the service had physical health and / or mental health needs, such as dementia. At the time of the inspection, 42 people used the service. The service had three separate dining rooms where people could eat.

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

People’s risks were not always managed safely. People’s risk assessments were not reviewed or completed to ensure they were kept up to date and reflected any changing needs. People’s care plans and risk assessments were reviewed monthly. However, not all actions relating to people’s care had been documented when there was a change in circumstances.

Where people were prescribed 'as required' (PRN) medication, the service did not always have protocols or guidance in place.

Personal protective equipment (PPE) was available for staff, such as disposable gloves to use to help prevent the spread of infection. However, we found during both days of inspection that staff were not always using the equipment provided when working with people.

We made a recommendation about staff use of PPE to help prevent the spread of infection.

We used the Short Observational Framework for Inspection (SOFI) during meal times that looked at people’s dining experience. We observed that there was limited interaction between staff and people.

The registered manager’s audit system had not been effective in finding the issues and risks that were found during our inspection.

There were effective systems in place to safeguard people from harm and abuse. The registered manager took the necessary action to implement the required learning identified from accidents and near misses.

People and their families, where appropriate, were involved in the planning of care and support needs. The registered manager had an effective system to ensure that staff received appropriate training.

People were involved in decisions about the décor of their rooms, which met their personal and cultural needs and preferences. People brought furnishings of their choosing that allowed personalisation of their rooms.

We observed staff supported people in a caring and compassionate manner. People’s care plans clearly evidenced the support they required and their personal preferences.

The service facilitated several theme days throughout the year to celebrate different events, which involved people, relatives and staff members.

People’s human rights were protected by staff who demonstrated a clear understanding of consent, mental capacity and Deprivation of Liberty Safeguards legislation and guidance

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

The last rating for this service was good (report published 19 May 2017)

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified two breaches. Regulation 12 the registered person failed to ensure risks relating to the safety, health and welfare of people using the service were assessed and managed safely and the registered person failed to ensure the proper and safe management of medicines. Regulation 17 The registered person had not established an effective system to enable them to assess, monitor and improve the quality and safety of the service provided.

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

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

Inspection areas

Safe

Requires improvement

Updated 7 December 2019

The service was not always safe.

Details are in our safe findings below.

Effective

Good

Updated 7 December 2019

The service was effective.

Details are in our effective findings below.

Caring

Good

Updated 7 December 2019

The service was caring.

Details are in our effective findings below.

Responsive

Good

Updated 7 December 2019

The service was response.

Details are in our effective findings below.

Well-led

Requires improvement

Updated 7 December 2019

The service was not always well led.

Details are in our safe findings below.