Chilton Croft Nursing Home

Chilton Croft Nursing Home is a residential service providing personal and nursing care for up to 32 people, some of whom are living with dementia, in one adapted building. At the time of our inspection there were 18 people using the service.

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

Since our last inspection the acting manager has worked along with support of partner agencies to make improvements to the quality and safety at Chilton Croft. Further work was needed to ensure all staff had access to care and risk management plans which reflected people’s current care needs.

We found some improvement in systems for auditing the quality and safety of the service. Further work was needed to ensure these included checks on all clinical equipment including suction machines.

Since the last inspection the registered manager had de-registered but remained a director. There had also been a number of changes in clinical leadership which did not ensure consistent, robust clinical oversight.

There were systems to ensure staff employed were suitable and had the skills and knowledge they needed. Staff told us they had received updated training and more regular supervision.

We received positive feedback from people and their relatives about the quality of care provided. We observed people being treated with respect and dignity. We recommended people’s preferences as to the gender of staff allocated to support them with personal care be assessed and reflected in care plans.

People were better supported to have choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the provider had accessed systems of support through the local authority to better address their responsibilities under the Mental Capacity Act.

There were effective procedures for preventing and controlling infection.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was inadequate (published 6 August 2022). There were breaches of regulation. At this inspection we found improvements had been made but the provider remained in breach of regulations.

This service has been in Special Measures since 6 July 2022. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

We undertook this focused inspection to check the provider had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the key questions safe, and well-led which contain those requirements.

The overall rating for the service has changed from inadequate to requires improvement based on the findings of this inspection.

We have found ongoing breaches in relation to safe care and treatment and good governance.

Full information about CQC's regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

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 Chilton Croft on our website at www.cqc.org.uk.

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.

Chilton Croft Nursing Home is a residential service providing personal and nursing care for up to 32 people, some of whom are living with dementia, in one adapted building. At the time of our inspection there were 29 people using the service.

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

Risks to people's health, safety and welfare were not managed effectively, placing them at risk of harm. We found large gaps in staff recording of support provided to people at risk of acquiring pressure wounds and inadequate fluid intake. The failure to follow risk assessments and ensure that people were assisted to reposition at regular intervals placed people at increased risk of skin breakdown. Medicines were not always safety stored.

People were at risk from a lack of trained and competent staff to meet their needs at night. There was one nurse and two care staff on duty to respond to people with a wide range of complex needs. We found that fire safety procedures were unclear, and staff did not have access to the information they needed to respond in an emergency.

The provider’s governance systems in monitoring the quality and safety of the service continued not to be effective and did not identify the shortfalls we found at this inspection. Risks to people's safety associated with improper operation of the premises had not always been identified and action taken to reduce these risks.

Safeguarding processes were not fully effective, and concerns were not always subject of sufficient scrutiny.

The systems within the service did not always promote people’s dignity and while some training had been accessed, changes had not been embedded into the culture of the service.

Feedback from people using the service and their relatives was inconsistent and while we received positive comments about the levels of support and quality of the meals, we also heard concerns about areas such as staffing at night and people’s access to meaningful activity.

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.

People benefited from a stable staff team and there was a clear process in place to check staff suitability before they started work.

Actions the provider told us they would take following our last inspection had not

been implemented. Following this inspection, the provider told us that they intended to work with a newly appointed consultant, health and Local Authority to making improvements.

Rating at last inspection and update

The last rating for this service was requires improvement (published 16 June 2021) and there was a breach of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations.

Why we inspected

We received concerns in relation to safeguarding incidents, the management of people’s nursing care needs, staffing and oversight arrangements. A decision was made for us to inspect and examine those risks. We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements. We have found evidence that the provider needs to make improvements. 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 requires improvement to inadequate based on the findings of this inspection.

You can see what action we have asked the provider to take at the end of this full report and you can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Chilton Croft 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 in relation to risk, staffing safeguarding and governance at this inspection. Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

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

The service supports people with dementia and other complex needs. Where incidents had occurred between individuals, they had not always been reported as required and sufficient scrutiny applied.

Staff responded to people in an intuitive and caring way however the systems in place to mitigate risks did not always work effectively.

The service did not have a formal mechanism for reviewing staffing levels to ensure that the numbers of staff reflected peoples changing needs. Some changes had been made to staffing levels prior to our visit and the number of staff on the day were adequate, although the roster needed greater clarity about how staff were deployed. A review of night staff is due to take place in conjunction with the fire safety inspection.

Management responsibilities were not always clear. Some audits were undertaken to check on quality but there were gaps and governance was not embedded.

There were systems in place to manage infection control. The service was clean and comfortable and there were no unpleasant odours. All staff undertook COVID-19 tests in line with the government guidance in order to protect the people they cared for. Visits by relatives had been facilitated to the service which was welcomed by staff and people using the service. The infection control policy was not up to date, but the registered manager assured us that this would be addressed as a matter of urgency.

The registered manager had ensured that all staff and people living in the service had the information they needed about vaccines to ensure that they could make informed decisions and there was a high take up of the vaccine.

People were supported by a kind and friendly staff team who knew them well. There was a clear process in place to check staff suitability before they started work.

People had good access to healthcare and regular surgeries were held at the service. Medicines were managed in a safe way.

The meals looked appetising and staff ensured that people had the support they needed.

The registered manager was visible within the service and knew each person well. Staff told us that they were well supported by the management team and proud of the fact that they had managed to keep the home free from COVID-19.

A consultant had been commissioned to assist the management team develop processes to drive improvements.

For more details, please find the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was Good (published 29 August 2018)

Why we inspected

We received concerns in relation to staffing and the management of risk. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from Good to Requires Improvement. This is based on the findings at this inspection. 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 Chilton Croft Nursing Home on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

At our last inspection we rated the service Good. At this inspection we found the evidence continued to support the rating of Good overall. Whilst we have rated the key question of Well-Led Requires Improvement. This was because we were notified earlier this year that the provider had admitted more people into the home that they are registered for. This was a breach of their conditions of registration of the home. We have written to the provider separately about this. There was no other evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

At the time of this inspection there was a registered manager in post. 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 registered manager was also a director in the provider company. We have referred to this person as the registered provider throughout this report.

People continued to receive a good standard of care. People we spoke with told us they felt safe living at the home. Risks were assessed and safety of people was monitored by staff on an ongoing basis.

Risks to people were assessed, monitored and updated as and when necessary. Action was taken to reduce the risk of incidents and information about risks to people were documented in their care records so that staff were aware.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. People received a service that was caring. Staff knew people's needs well and were responsive and supportive.

The service had a complaints procedure which was made available to people and their relatives. People were happy living at the home and had no complaints.

People who lived at the home, relatives and staff told us the service was well led. Staff were aware of their roles and responsibilities and were well supported.

Further information is in the detailed findings below.

Chilton Croft is a nursing home and can accommodate up to 32 people. Some people were living with dementia or had a physical disability.

The registered manager was present throughout the inspection and participated fully. 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 spoke highly of this service telling us that they were satisfied and happy living here. We observed staff to be kind, patient and demonstrating meaningful relationships with people. Relatives told us that the staff responded to individual health and care needs of people. They had confidence in the clinical and care staff and believed they had the skills to support their relative appropriately. We found that nursing staff had the confidence and skill to provide a good level of clinical intervention that met peoples nursing needs well. Relatives felt that any concern they raised would be addressed and gave us examples of this occurring. Our observations and review of records concurred with these views.

Staff were welcoming and hospitable to everyone who visited. They were positive about working as a team and enjoyed their jobs. Staff spoke of good fluid communication within the team. Staff were appropriately trained and supported as there was always nurses and management of the home available to them. There were known aims and values that staff worked towards. Staffing was structured appropriately with people understanding their role and responsibility.

People experienced an environment that was clean, fresh and ordered. They had access to appetising food that met their needs. People spoke highly of the food. Visiting health professionals also spoke highly of the service and commented that consent was in place. People receiving treatment understood who the health professional was and assessment and treatment options were explained. Nurses were found to have the correct clinical skills to meet people’s health needs.

Records were well kept. Care plans were very ordered and staff felt they could rely on the information contained in these records to guide them appropriately.

Management of the home was responsive to ideas and critique no matter from where this came, people, their relatives, staff, other professionals or CQC. We found that issues raised had been addressed well and had been sustained. There were systems to listen and respond as well as monitor the quality and safety of the service.

There was a Health and Safety Executive [HSE] investigation relating to a moving and handling avoidable harm death still outstanding. Matters are as yet not concluded and we await the outcome from HSE and any potential action they may take on this historic matter.

The inspection team consisted of three inspectors. We spoke with six people who used the service, and one relative. We observed care and support in the lounge area and throughout the service over eight hours spent at the service. We looked at eight people's care records. Other records viewed included policies and procedures, medication management records, health and safety checks, satisfaction questionnaires completed by people who used the service, quality monitoring systems used by the manager and we toured most of the communal areas of the service, along with clinic areas and medication storage. We considered our inspection findings to answer questions we always ask; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

Is the service safe?

Following major concerns in our previous inspections undertaken on 5 December 2013 in relation to unsafe moving and handling practices we found significant improvement in this area. Risk assessments to keep people safe when moving and handling people were detailed and contained all the information needed for staff to follow, including the correct equipment to use. Safer systems were in place for moving and handling people at Chilton Croft.

In our previous inspection undertaken on 25 February 2014 we had minor concerns in relation to the provider not having robust systems in place to address medication administration and recording errors identified within their own internal auditing processes. At this inspection we found that the systems in place for managing medication continued to be ineffective and the levels of mistakes were putting people at risk. We found that diabetes management and assessments of sore skin could be improved and were not reflecting best practice. Preventative safe practice was not being strived for in these two areas.

CQC monitors the operation of the Deprivation of Liberty Safeguards which apply to care homes. Following our concerns raised in our previous inspections we reviewed the provider's application and use of legislation of the Mental Capacity Act (MCA) 2005, Deprivation of Liberty Safeguards (DoLS) and associated Codes of Practice. We saw that there was a policy and procedure in place to guide staff on these issues and that nine staff had received training. We continued to find inconsistent practice. We found in some cases that people's capacity had not been fully considered within assessment and care planning arrangements and capacity assessments although started had not been completed. We saw that referrals to the local authority (who are responsible for assessing DoLs applications) were being made for some people. However the provider was unable to tell us how they were managing this area of people's care following a recent court ruling which could potentially affect others using the service.

Is the service effective?

Care at Chilton Croft was striving to be effective. They had developed several ways of consulting people at the service through questionnaires, meetings and informing them of change with newsletters. People who used the service responded positively to these consultations. One relative told us, 'My relative is very happy here. The nurse talks to us all the time. I am confident we would be informed of anything significant.'

The systems in place to regularly assess and monitor the quality and safety of the service provided were still not effective. Audits were carried out to identify shortfalls in medication practices, health and safety matters and infections control; however, the action plans in place to address identified shortfalls were not robust to ensure as far as possible that the events did not occur again. Best practice and expertise in response to older people's conditions was not being demonstrated.

Is the service caring?

One person told us, 'The staff are nice, polite and respectful. I speak to the manager and the nurse on a regular basis and they listen'. We saw that the staff interacted with people living in the service in a caring and respectful manner. People using the service told us staff were caring and met their needs. One person told us, 'They treat me ever so well'. We saw care staff speaking respectfully to people, lowering themselves to the eye level of people and speaking clearly. We saw care staff offering people choice in what activities to undertake, and what drinks they preferred.

Privacy and dignity was respected when supporting people with personal care. People were covered when hoisted in communal areas, bedroom doors were closed as needed.

Is the service responsive?

People using the service were provided with the opportunity to participate in activities which interested them. People's choices were taken in to account and listened to. This included regular activities that people had requested and been consulted about. People told us that they had access when needed to medical professionals.

We found that the service was responsive to some matters that had been brought to their attention. An example being the need for a specialised sling for hoisting, pointed out by another professional. However, an example of not being responsive was the five month timescale set to review the medication policy and a lack of effective response to missing controlled drugs.

Is the service well-led?

We found the provider was working to address the issues we had previously pointed out to them. Whilst the provider was keen to put things right, they were not able to demonstrate that learning was being transferred from one area to another. For example, a keen focus had been placed upon safe systems of moving and handling and therefore people were safer in this area now, but the same approach had not been adopted on medication management. We were concerned that the provider was not able to demonstrate that they were being proactive in effectively monitoring the safety and quality of the service independently.

At this follow up inspection we checked to see if the required improvements had been made, and found further evidence of a lack of leadership and management of the service. This was because the provider had failed to implement a robust quality checking system that managed risks and assured the health, welfare and safety of people who received care. This was confirmed in our discussion with a visiting health professional who told us they had been visiting the service in professional capacity over a period of about 10 years. They told us, 'There is a lack of proper clinical leadership in the home, and that well trained nurses were needed'.

We found that there was a continued lack of understanding of when the legal requirements of the Mental Capacity Act 2005 should be applied. We also observed further incidents where people were not being treated with dignity and respect.

We spoke with one person who used the service. They told us, 'I am very happy with my care, I feel a lot better of late and the staff are looking after me'. We spoke with two relatives during our inspection. One relative told us that this was the first home they had looked at and was 'Impressed'. They commented, 'Staff are very friendly, my relative is independent, and they like the food and the staff'. One relative told us 'I visit weekly, and have seen an improvement in the home in the last few months; I am pleased with the care given to my relative'.

At this follow up inspection we checked to see if the required improvements had been made, and found further evidence that the provider had failed to properly assess people's needs and ensure that they had been provided with the correct moving and handling equipment, that ensured their welfare and safety.

We spoke with one person who used the service who told us that they, 'Felt safe' in the hoist when being moved by staff, 'But not when it swings about'. They told us that, 'The hoist is not that comfortable, although I understand it has to be used'. This person also told us, 'The staff here are lovely and really look after me'.

We saw that the 'Residents and relative's questionnaires' had been completed by some relatives to gain their views about the service. All of the feedback was positive, referring to the service as 'Excellent' or 'Very satisfied'. Although there were some positive comments about the quality of the service, we found that people were not always protected from the risks of inappropriate or unsafe care and treatment. We found that the leadership and management of the service had not identified risks to people using the service, which meant that their care was not always meeting their needs. This was because the provider did not have an effective system in place to identify, assess and manage the risks to the health, safety and welfare of people who used the service and others.

We saw that people's privacy and dignity was not always respected. We found that before people received any care or treatment they were not asked for their consent and the provider had not acted in accordance with the legal requirements of the Mental Capacity Act 2005. People were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to manage medicines.

People were not experiencing care that met their needs. We found that where people needed support to move their care was not planned and delivered in a way that was intended to ensure their safety and welfare. We found that where three people had lost weight this factor had not prompted revision of their risk assessment to ensure that manual handling equipment was still safe to use. We found that staff were not adequately trained to recognise where peoples manual handling needs had changed, which placed people at risk of harm.

We saw that people were provided with choices, about every day decisions, including food. We observed the chef discussing meal options with people, using a menu with photographs of the options available. People spoken with told us the food was good and they had plenty of options. One person commented, 'Excellent home, excellent food, excellent staff'.

Overall we found that people's dignity and independence was respected. We saw one occasion where staff needed to be reminded about respecting people's privacy. We spoke with a person visiting the service. They told us, 'My relative has received nothing but kindness since day one' and 'It is absolutely lovely here, the care is really good and the carers are really nice".

We saw evidence that the care was provided to people to meet their individual needs. We saw that there had been an improvement in recording information so that people were protected from the risk of malnutrition. Improvements had been made to ensure that people were being assessed appropriately with regards to their capacity in accordance with the Mental Capacity Act 2005.

We found we had to bring the providers attention to a person's rapid weight loss and the lack of trained staff available, on duty to change a person's catheter. Although, the provider took immediate action to address these matters and reduce the immediate impact on these people's health and well-being, their own quality monitoring systems had failed to identify these issues.

We saw evidence that care provided to people did not meet their individual needs; we found evidence that people's care had not been managed in a way that protected them from the risk of harm or further decline in their health or wellbeing.

We found that key information in the records such as risk assessments were not accurate. We found that key documents were missing from the care plans to support people's needs.

We saw evidence that the service had used forms of restraint as a method of care to people with challenging behaviours. We found that these people were not assessed appropriately in accordance with the Mental Capacity Act 2005 Deprivation of Liberty Safeguards (MCA DOLS.)

We found that people were not protected from the risk of malnutrition and associated weight loss. We found that unplanned weight loss was not managed appropriately.

We found there was a sufficient number of staff on duty to support the needs of people using the service.

People were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to manage as required PRN medication.

During our inspection in January 2013 we spoke with four people who used the service. All four people told us that they felt well cared for and that staff attended to them promptly when they had pressed their call bell. One person told us that they found the staff 'Kind and considerate and nothing was too much trouble.'

People told us that they had a choice of meals and that the food was of a good standard. Everyone we spoke with said that they felt well and safe.

As part of the inspection carried out in January 2013 we examined two people's care records. We reviewed assessments completed prior to admission to the service. We also reviewed the risk assessments for both people. Both care plans had been updated since the last inspection in September 2012. This included a risk assessment for a person who required bed rails. The risk assessment was dated 9 September 2012.

A consent record was also in place that had been signed by the person's relative. Another consent record for the use of a lap belt was seen and an up to date risk assessment and consent record was in place for this person dated September 2012. This meant that people had been consented and consulted with regard to their care and treatment.