Chalgrove Care and Nursing Home

Updated 23 September 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by three inspectors.

Service and service type

Chalgrove is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Chalgrove is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since our last inspection . We sought feedback from the local authority and health commissioners. Due to technical problems, the provider was not able to complete a Provider Information Return (PIR). A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used information gathered as part of monitoring activity that took place on 9 June 2022 to help plan the inspection and inform our judgements. We used all this information to plan our inspection.

During the inspection

We spoke with eight people who used the service and one relative about their experience of the care provided. We spoke with nine members of staff including the registered manager, operations manager, nurses, senior staff, health care assistants, activity staff, chef and administrator. We also received written feedback from seven staff sharing their experience of the service. We spoke to three health and social care professionals who work with the service.

We reviewed a range of records. This included 10 people’s care records and multiple medication records. We looked at two staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed

Updated 23 September 2022

About the service

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.