We carried out a review of the data available to us about The Chapel House Nursing Home on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about The Chapel House Nursing Home, you can give feedback on this service.
The Chapel House Nursing Home is registered to provide accommodation with personal care for up to a maximum of 35 older people. There were 23 people living at the home at the time of our inspection, some of whom were living with dementia.
People’s experience of using this service and what we found
We have made a recommendation regarding the systems in place to monitor the quality and safety of the service as they were not always effective. Audits did not highlight all the issues identified during the inspection, and when issues were identified, action plans were not always created to reflect what actions would be taken. A new suite of audits had just been implemented to try and improve the governance of the service.
People received their medicines from appropriately trained staff, although records regarding the management of medicines were not always robustly maintained.
Infection prevention and control policies and procedures were in place to help reduce the risk of infections, including COVID-19. The home was clean and cleaning schedules were being further developed to help minimise any risk of infections being spread. Personal Protective Equipment was available to all staff and visitors and we observed this to be worn appropriately and there was a system in place to ensure staff were undertaking COVID-19 tests in line with current guidance. Visits to the service were carried out safely in line with current government guidance.
People and their relatives told us the home was safe. Staff were aware of safeguarding procedures and knew how to report any concerns they had. Risks to people had been assessed and were managed and there were sufficient numbers of safely recruited staff available to support people. Accidents and incidents were managed safely. Records showed that appropriate actions were taken following any accidents.
Systems were in place to ensure Deprivation of Libert Safeguards (DoLS) applications were made and managed effectively. 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.
Staff received regular supervisions and an annual appraisal and told us they felt well supported. Training was available and staff told us they were up to date with their mandatory training, although records did not always support this. Relatives told us staff had the skills to support their loved ones.
People had access to plenty of food and drinks and their nutritional needs were assessed and met, although feedback regarding meals was varied. People's health and well-being was routinely reviewed, monitored and assessed and GP's were contacted when people were unwell.
People were supported and encouraged to maintain relationships and participate in activities and events of interest to them. A new team of activity staff were in the process of being recruited to enhance the current activities available. People and their relatives knew how to raise any concerns they had and were confident they would be listened to.
Feedback from people and their relatives regarding the care provided was positive. Staff were described as kind and caring, they treated people with respect and encouraged people’s independence. People were supported to be involved in their care decisions as much as possible. Family members were also included in care planning to ensure people’s needs and preferences could be met.
Relatives told us the home was managed well and that communication had improved since the new manager came into post. They told us they were kept well informed through newsletters and meetings and were able to provide feedback about the home. Staff told us they enjoyed their jobs, liked working in the home and were well supported. They told us they would recommend it to others and would be happy for their family members to live there if they required care.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
This service was registered with us on 14 August 2020 and this is the first inspection.
The last rating for the service under the previous provider was outstanding (published 20 December 2017).
Why we inspected
This was a planned inspection.
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.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.
We found the following examples of good practice.
¿ Comments from relatives included; "We had regular emails and newsletters with updates really regularly", "We had visits to see [Name] in the pod. It was clear that staff knew [Name] really well. We had ultimate confidence in them" and "We were looked after and supported during [Name's] end of life care. We were able to have as much time as we needed. This made such a difference."
¿ Relatives told us they had previously participated in garden visits and inside pod visits with screens in place. They said these were pre booked and well managed.
¿ All visitors were asked to complete a health screening form, have their temperature checked and were provided with face masks to wear throughout their visit. Full personal protective equipment (PPE) was available for all visitors along with access to handwashing facilities and hand sanitiser.
¿ The service had increased the cleaning schedules and routines to reduce the risks of cross infection. The environment was very clean and hygienic.
¿ We observed staff to be wearing the correct personal protective equipment (PPE) throughout the inspection.
¿ People and staff were taking part in regular COVID19 testing.
¿ People had individual risk assessments in place that reflected their specific needs in relation to COVID19.
¿ Staff had all received training to meet the requirements of their role and for the management of COVID19.
Further information is in the detailed findings below.