Chalgrove Care and Nursing Home

Chalgrove is a residential care home providing personal and nursing care for up to 60 people. The service provides support to older adults, some of whom live with a dementia. At the time of our inspection there were 53 people using the service. The home is divided into two adjoining buildings which provide accommodation and are connected by a corridor.

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

Risks to people had not always been assessed, care plans did not always include details of risks to people, and actions in place to mitigate identified risks had not always been taken. Quality assurance systems and processes had not been effective at identifying shortfalls in the management of risks to people.

People felt safe. Staff understood their role in recognising potential abuse and knew the actions needed if they had concerns. People had their medicines managed safely and were protected from avoidable infection. Staff had been recruited safely and staffing levels met people’s needs.

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.

The management of Chalgrove was described as open, friendly, professional with good teamwork and visible leadership. Staff were clear about their roles, felt involved in the service, listened to and appreciated. Learning was shared with staff. Links with other professional bodies had been established which supported up to date best practice.

People were respected as individuals and received care that recognised their care needs, choices and lifestyles. A range of activities reflected people’s culture, interests and hobbies. People had an opportunity to be involved in end of life planning that included any cultural or spiritual needs. A complaints process was in place that people felt confident to use if needed.

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 (published 23 January 2018).

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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.

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 changed from good to requires improvement based on the findings of this inspection.

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

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Chalgrove Care and 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 monitor the service and will take further action if needed.

We have identified breaches in relation to the management of risks to people and quality assurance processes.

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

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.

At our last comprehensive inspection in October 2016, we found breaches of the legal requirements in relation to person-centred care, safe care and treatment, and good governance. Care and treatment was not always satisfactorily planned to meet people’s needs. Topical medicines such as creams and gels were not managed safely. Care given was not always accurately recorded. We also made recommendations regarding keeping staffing levels under review, keeping records of powers of attorney, and making life story information more readily available for people and staff. We rated the service ‘requires improvement’ in Safe and Responsive, and overall.

We also undertook a focused inspection in May 2017 in response to concerns relating to the safe management of swallowing difficulties, pressure area care and staffing levels. We found no breaches of regulation. Systems were in place to manage the risk of choking and to protect people from developing pressure ulcers. There were enough staff on duty to provide the care people needed.

When we completed our previous inspection in October 2016 we found concerns relating to the record keeping aspect of good governance. This topic area was then included under the key question of Responsive. We reviewed and refined our assessment framework and published the new assessment framework in October 2017. Under the new framework this topic area is included under the key question of Safe.

Following the inspection in October 2016, we asked the provider to complete an action plan to show what they would do and by when to meet the legal requirements. At this inspection we found these legal requirements had been met.

Chalgrove Care and 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.

The care home accommodates up to 60 people in two wings of one adapted building. Edwardian wing accommodates up to 35 people who require nursing care. There were 31 people staying there at the time of the inspection. The remaining beds are in Tudor wing, where nursing care is not provided. There were 23 people accommodated there at the start of the inspection. Accommodation is in individual bedrooms, some of which are large enough to share in the event a couple are admitted. The service operates a ‘step down beds’ scheme with some local hospitals, where people who no longer require acute care in hospital are admitted for further recuperation or until ongoing care is in place.

The registered manager had recently left the service and had applied to cancel her registration. A replacement manager had just started in post. They intended to apply to register. 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.

People were treated with kindness and respect by caring staff and almost all of the interactions we observed upheld people’s privacy and dignity. We have made a recommendation regarding reminding staff of their responsibilities in relation to privacy and dignity.

People were protected from abuse and avoidable harm. The staff recruitment process included checks to help ensure staff were of good character and suitable to work in a care setting.

Staff morale was good and staff spoke enthusiastically about their work. People’s care needs were met by staff who were supported through training and supervision to be able to perform their roles effectively. Staffing levels were calculated using the provider’s dependency tool and were usually sufficient to provide the care people needed in a safe way.

People’s rights to consent to their care or have it provided in their best interests were protected because staff worked in line with the requirements of the Mental Capacity Act 2005. People’s consent was sought to their care. If people lacked the mental capacity to give consent to some aspect of their care, a best interests decision was made about this, with a view to minimising any restriction on them.

Care plans were personalised to the individual, and provided clear instructions to staff about what care should be provided and how. They were based on assessments of need undertaken before people came to stay at the service. They were reviewed regularly and were kept up to date. Staff kept clear records of the care provided.

People were supported to make decisions about their preferences for end of life care. Staff had training in end of life care. Where necessary, medicines that might be needed for relief of pain and distress were prescribed and kept in stock.

People had a choice of food and drink and their nutrition and hydration needs were met.

People had the support they needed with their health needs, including referral to doctors and other health professionals.

Medicines, including skin creams, were stored and managed safely. There were clear instructions for staff about how and to which area to apply skin creams.

Risks to people who used the service, and general risks to people, staff and others, were assessed and managed.

The premises and equipment were kept clean and free of unpleasant odours. There were adequate hand hygiene facilities and staff observed infection control precautions, such as the use of personal protective equipment.

Property and equipment maintenance was carried out regularly, with the required checks in place. There was a procedure for reporting faults, which were attended to promptly by maintenance staff or, if necessary, external contractors. We identified problems with two people’s bed rails. Remedial action was taken immediately, including the provision of a thicker air mattress and repairs to a bed rail that would not stay up. Managers undertook an audit of each bedroom that day, in case there were any other unknown faults.

Management and governance arrangements were robust and had brought about improvements. Information from previous inspections, other stakeholders and the provider’s own quality assurance processes was used to drive these improvements. Feedback was sought from people, their relatives and staff. Concerns and complaints were taken seriously and seen as an opportunity for learning.

Chalgrove Care and Nursing Home is a care home for up to 60 adults who require care due to illness or frailty. At the time of the inspection there were 50 people using the service, most of whom were older people. The Edwardian wing accommodates up to 35 people who require nursing care, and the Tudor wing up to 22 people who need residential but not nursing care. Accommodation is in individual bedrooms, some of which are large enough to share in the event a couple are admitted. The service operates a ‘step down’ scheme with some local hospitals, where people who no longer require acute care in hospital are admitted for further recuperation or until ongoing care is in place. Two nursing and eight residential beds are allocated to this.

The service had a registered manager, as required under the terms of its registration. 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 we found shortfalls in relation to the safe management of topical medicines, such as skin creams and ointments. These were a breach of the regulations relating to safe care and treatment. We will review the management of medicines at the next comprehensive inspection.

At the last inspection we also found shortfalls in relation to care planning and record keeping. These were a breach of the regulations relating to person-centred care and good governance. We will review care planning and record keeping at the next comprehensive inspection.

At this inspection, people were positive about the care they or their relative had received. They said they got the care they needed, that their food was good and that there were enough staff to provide the care and support needed.

Systems were in place to manage the risk of choking where people had swallowing difficulties. These had been reviewed since concerns had been raised about safe swallowing. Commissioners had visited the service and made recommendations about the management of swallowing difficulties. The service was working to implement these.

The people we saw eating had been assisted into a more upright position to help them swallow without choking. However, one person, who had recently finished their first course of a meal, had slipped down the bed.

Staff had asked GPs to make referrals to speech and language therapists for people who had swallowing difficulties. However, records did not always show clearly when this was done and why.

Standard national descriptors of food and fluid textures for people with swallowing difficulties were not used consistently across the service. Safe swallow plans did not all reflect the standard national descriptors. These had been based on assessments from community or hospital speech and language therapists who had assessed people’s swallowing difficulties. The professionals had not always used the standard national descriptors.

People’s safe swallow plans were clearly displayed in people’s rooms for staff to refer to when they assisted someone with eating and drinking.

Written information sheets that were used when people were admitted to hospital reflected the recommendations in safe swallow plans. However, these sheets did not show the date they had been created.

There were systems in place to protect people from developing pressure ulcers. For example, people who were at risk were supported to change position regularly.

Most records for prescribed creams contained the required information. There were clear instructions for administration, including body maps to show where to apply them. However, three records did not contain a body map or clear instructions. We will review the management of medicines, including prescribed creams, at the next comprehensive inspection.

There were enough staff on duty to provide the support people needed. Dependency tools were used to help inform staffing levels.

Chalgrove Care and Nursing Home is a nursing and residential home registered for up to 60 predominantly older people, who may be living with dementia. The service is divided into two wings, each with their own lounges, dining rooms and bathing facilities. Edwardian wing is predominantly for people who require nursing care, and Tudor mostly accommodates people who need residential care without nursing. Until a very recent reorganisation, both wings had mixed nursing and residential care. At the time of our inspection, there were 48 people accommodated.

The service was required as a condition of its registration to have 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. The home manager was in the process of applying to register as manager. They had transferred to Chalgrove Care and Nursing Home in August 2016 from another home they were managing within the Agincare group. They had worked as the deputy matron at Chalgrove Care and Nursing Home between October 2015 and March 2016. Their predecessor has applied to cancel their registration.

The service is registered for the regulated activity of ‘diagnostic and screening procedures. We have advised the provider that this is not required and have asked them to apply to remove this regulated activity from the registration.

There was a homely feel to communal areas and we observed people enjoying the company of staff who were supporting them. Staff treated people in a caring and respectful way. They spoke about people as individuals and knew about their personal preferences. Information about people’s life histories was gathered to help staff get to know them. This was stored in people’s care records but not in their rooms, where it would be most easily accessible to people, their relatives and staff. We have recommended the service reviews how it makes these readily and easily available for people and care staff.

People were protected against the risks of potential abuse. Staff had a good understanding of how to keep people safe and their responsibilities for reporting accidents, incidents or concerns.

During the inspection there were sufficient staff available to provide people’s care. However, during and after the inspection we received mixed feedback about staffing from people, their visitors and staff. Some of this suggested staff were sometimes so busy that care was hurried or delayed. Staffing levels had been reviewed shortly before the inspection. We have recommended the provider continues to keep staffing levels under review to ensure there are always sufficient, suitably skilled staff on duty.

People and their relatives spoke positively about the abilities of the staff. For example, a person living at the service told us, “The nurses are excellent and very professional”. Safe recruitment practices were followed before new staff were employed to work with people. Staff were supported through regular training and supervision to perform their roles. Nurses were able to access the required professional development to maintain their professional registration.

The staff we spoke with were motivated and enthusiastic about their roles. They had confidence the home manager would listen to their concerns, which would be received openly and dealt with appropriately.

People and their visitors spoke positively about their experiences of care at the service. However, our findings were not all consistent with this. Some people had needs that were not addressed by care plans. Care plans were regularly reviewed but did not all reflect people’s current needs and some care plans contained insufficient detail about how people’s needs were to be met. Whilst people often received care as specified by their care plan, this was not always accurately recorded so that staff could see when particular aspects of care were next required. You can see what action we told the provider to take at the back of the full version of the report.

An activities worker had recently started in post, following the departure of the previous activities worker not long before. We observed people in communal areas doing jigsaws and involved in group activities such as quizzes. However, a number of people were cared for in bed or preferred to stay in their rooms. On one day, we saw that a person awake in bed had no stimulation such as music, radio, television or tactile objects; this was a person who was said to enjoy classical music and the following day this was provided. Prior to the inspection we had received feedback about a lack of activity and stimulation for people. Following the inspection, the management team informed us there had always been a daily activity schedule including visiting entertainers and daily activities with other members of the care team.

People’s prescribed oral medicines, injections and skin patches were managed safely. However, there were shortfalls in the recording of prescribed creams that meant we could not be sure these were always administered as prescribed. One person had dry skin on their legs and a large remaining volume of emollient cream supplied in June 2016, which was inconsistent with the cream being applied twice a day and as needed since then. You can see what action we told the provider to take at the back of the full version of the report.

People’s health care needs were monitored and any changes in their health or well-being prompted a timely referral to their GP or other health care professionals.

People’s consent was obtained for their care and treatment. Where there were concerns about their ability to give valid consent in relation to particular aspects of their care, the service followed the requirements of the Mental Capacity Act 2015. However, where people had appointed a lasting power of attorney, their records were not always clear about the nature of this. We have recommended the service ensures there is clarity in people’s records regarding the type of power of attorney held, whether this has been registered and whether it has any specific restrictions.

People told us they were satisfied with the food and had choices about what they had to eat. People received the support they needed to eat and drink and where people had particular needs around how much to drink, their fluid intake was monitored appropriately. Up to date records were kept of people’s dietary needs and preferences.

Risks to people’s personal safety had been assessed and plans were in place to minimise these risks. The building was maintained, refurbishment having been undertaken since our last inspection. There were regular checks and inspections to ensure the premises and equipment remained safe. People involved in accidents and incidents were supported to stay safe and action was taken to prevent further injury or harm.

There was a programme of regular checks and audits by the home manager and staff, and by operations manager who oversees the home. Accidents and incidents were recorded and monitored to look for developing trends that indicated improvements were needed, as were complaints and safeguarding concerns. The nurses and management team responded positively to any shortcomings we identified during the inspection.

We spoke with seven people, four staff and the acting manager. We observed people in both Edwardian and Tudor lounges and dining areas.

People told us they were satisfied with the care and support they got at Chalgrove Care and Nursing Home. One person said 'I get the care I need' and another person said, 'I am very comfy here. I get on with the staff they are superb'.

During observations we saw that staff knew individual's well and understood their needs. We observed that overall staff were caring and provided care and support in a sensitive way.

We found people's care and treatment was planned and delivered in a way that ensured their safety and welfare.

People who use the service, staff and visitors were protected against the risks of unsafe or unsuitable premises.

There was an effective complaints system available. Comments and complaints people made were responded to appropriately.

This inspection was to follow up on the warning notice issued for shortfalls in infection control identified at our inspections in April and October 2013.

We undertook a tour of the building, checked the cleanliness of fifteen bedrooms and communal bathrooms and toilets. We spoke with the acting manager and maintenance worker and checked the cleaning schedules.

We spoke briefly with people as we toured the building. One person told us 'it's very good', when we asked about the cleanliness in the home.

People were protected from the risk of infection because appropriate guidance had been followed. People were cared for in a clean, hygienic environment.

We spoke with 26 people, three relatives and two health care professionals. We also spoke with eight staff, the acting manager and the provider's quality manager. We observed five people during a SOFI observation and in addition to this we observed people in both communal and bedroom areas.

Comments from people about Chalgrove Care and Nursing home included; 'They look after us well', 'They know I'm not happy but you can't fault the staff', 'There is room for a little improvement', 'Care is fairly good' and 'Carers ever so good and very polite and nice'.

We found some people did not experience care, treatment and support that met their needs and protected their rights. This was because some people's needs were not fully assessed and planned for and the care and support some people needed was not delivered.

At this inspection we reviewed the actions taken by the provider to address shortfalls in infection control identified at our inspection in April 2013. We found that there were continued shortfalls in infection control. This meant that potentially that people were not fully protected from the risk of infection because appropriate guidance had not been followed.

We carried out an unannounced inspection of Chalgrove Care and Nursing Home in response to information of concern we received. We found there were sufficient staff on duty. However, we found minor concerns in infection control.

During the inspection we spoke with six individuals who lived at Chalgrove Care and Nursing Home. We also spoke with one visitor and nine members of staff including the acting manager.

Records showed that people's needs were assessed and care plans were completed. However, we noted inaccuracies within two of the three records we looked at. One individual we spoke with told us 'I'm very happy here, they look after me really well, I couldn't ask for more'. Some people we spoke to told us they did not feel there were enough activities offered to people living at Chalgrove Care and Nursing Home.

We found some infection control issues that meant people were not always cared for in a clean, hygienic environment.

We found there were enough qualified, skilled and experienced staff to meet people's needs.