12 July 2022
During an inspection looking at part of 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.