Chollacott House Nursing Home

Updated 11 November 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 one inspector, an assistant inspector, a specialist advisor who was a nurse and an Expert by Experience, who had consent to phone and gain feedback on the care provided by the service from people's relatives. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Chollacott House 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. Chollacott House 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 inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with the registered manager, 10 members of staff and one health care professional. We also spoke with five people and 10 relatives. We reviewed a variety of documents. This included six care records and a selection of healthcare records including medication records, three staff recruitment and training files and a selection of audit and governance records.

Updated 11 November 2022

About the service

Chollacott House Nursing Home (hereafter referred to as Chollacott House) is a residential home that provides personal and nursing care for older people. Chollacott House accommodates 42 people in one adapted building. At the time of the inspection 29 people lived at the service.

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

People’s care records were not always reflective of their care or health needs. We found aspects of people’s care experience could be improved further. For example, some people were not treated in a manner that always promoted their dignity. Furthermore, people’s social care needs were not being attended to and there were prolonged periods of time where people did not receive meaningful engagement with staff.

People were supported by staff who understood how to recognise and escalate safeguarding concerns. There were adequate numbers of staff to support people with their care and health needs. Staff had been recruited safely and received an induction and supervision. Staff followed good hygiene practices.

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 understood their roles and responsibilities. Quality assurance systems were not always effectively used to monitor and drive improvement. The service had partnerships with other agencies such as health and social care professionals to meet people’s needs.

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 26 September 2017).

Why we inspected

The inspection was prompted in part due to concerns received about the quality of the service provided to people. As a result, we undertook a focused inspection to review the key questions of safe, caring, responsive and well-led only.

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, caring, responsive and well led sections of this full report.

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

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Chollacott House Nursing Home on our website at www.cqc.org.uk.

Enforcement and Recommendations

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 of regulation in respect of person -centred care and good governance at this inspection.

We have also made three recommendations in relation to manging risk, medicines and respecting people’s dignity and privacy at this inspection.

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.