Chorleywood Manor Care Home

Updated 17 May 2023

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 completed by three inspectors (two spent time in the home another supported by reviewing documents) and two Expert by Experiences. 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

Signature at Chorleywood 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. Signature at Chorleywood is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

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

Notice of inspection

This inspection was unannounced.

Inspection activity started on 1 March 2023 and ended on 29 March 2023. We visited the service on 1 March 2023.

What we did before the inspection

We spoke with the local authority to gain their experiences of 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 reviewed the information we hold about the service and reviewed the provider’s website. We used all this information to plan our inspection.

During the inspection

We spent time in the home speaking with 11 people and seeing how people were supported and treated by the staff. During our time on site, we looked at the care of 3 people, oxygen management, and we looked at how medicines were administered and managed for 7 people. We spoke with 11 members of staff and the registered manager, deputy manager and we had e-mail contact from the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We telephoned and spoke with 12 relatives. We reviewed the care records for 11 people. During the inspection we reviewed 2 staff’s recruitment checks, audits, fire and equipment safety records. Complaints, compliments, and newsletters.

Updated 17 May 2023

About the service

Signature at Chorleywood is a residential care home providing personal care and accommodation for up to 100 people. The service provides support to adults including adults living with different forms of dementia. At the time of our inspection there were 68 people using the service.

The home is a purpose-built building over three floors. There is a section of the home specifically for people living with dementia who need additional support, this is called the ‘reminiscent’ community.

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

We found many issues with how oxygen therapy was being managed at the home. There were a lack of processes and checks to ensure additional oxygen was stored and managed safely. Staff had not had training on oxygen therapy and the associated risks. The management and provider were not thoroughly monitoring and assessing this aspect of people’s care to assure themselves and others everyone was safe in relation to the use of oxygen.

The registered manager and provider started taking action to correct these issues as soon as we told them about these safety issues. We asked them to send us an action plan which they did, detailing how they were going to correct these safety issues. The registered manager also talked us through what they had done and would be doing moving forward.

We found some other issues connected to people’s health and wellbeing such as not promoting falls and pressure care safety. These concerns and the safety issues connected to oxygen therapy had not caused any harm to people, but there was a potential risk they could. Improvements were also required around how managers and the provider assessed some aspects of the quality of the care provided.

People and their relatives felt safe at the home. One person said, “I feel that I’m in a safe place. They [staff] are always popping in and out during the day when I’m here in my room.” Another person said, “The staff are extremely co-operative, very nice people. They are here for you.” A person’s relative told us, “Yes, I’m very confident that [relative] is safe and happy. [Relative] has been here for [number of months] and the communication is very good, they [managers] tell me what's going on and they ring me.”

The home was clean, and staff followed safe hygiene practices. There had been a recent COVID-19 outbreak but this was manged in a safe way. One person told us, “The cleanliness is good, they [staff] are forever cleaning.” A person’s relative told us, “It’s immaculate.”

People were supported by enough staff who had been safely recruited. Some people raised delays with requests for support in the mornings which we told the registered manager about. Actions were also being taken to increase the recruitment of permanent staff at the home to provide a better continuity of care for people.

Staff spoke well of the support they received by colleagues and managers to perform well in their jobs. Despite staff views, we found managers were not always supporting staff to maintain their knowledge in their work. We have made a recommendation about this.

Staff and managers sought help for people when they were unwell and supported people to be as healthy as possible.

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 staff and managers were kind and thoughtful towards the people they supported. One person said, “The staff are lovely, kind and respectful. I think they listen. All my personal care is done well. I like [name of member of staff] especially, we have such a laugh.” A person’s relative told us, “Yes, [relative] is clearly happy. [Name of relative] is happier now than they have ever been. They [staff] encourage all [relative’s] talents, they are less anxious, doesn’t worry and enjoys the company and stimulation.”

There was a social atmosphere to the home with staff spending time with people. Many events took place to help people feel included, happy and at home. One person’s relative told us how staff had supported their relative to make friends when they first moved to the home, “[Name of relative] has made some special friends of their own age which is so good.”

Complaints were processed in an open way and lessons were learnt from these. People were confident about making suggestions and raising issues which were important to them, and they felt improvements took place as a result of doing this.

Although there were some issues with how managers and the provider checked some aspects of the quality of care people received, there were also positive aspects too in terms of the other audits and checks the managers and provider were completing. The managers, provider, and staff had created an open positive culture in the home to benefit the people living at the home.

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

Rating at last inspection

This was the service’s first inspection as the provider had made a change to their legal status. This service was registered with us on 1 December 2021, and this is the first inspection following this change. The last rating for the service Sunrise at Chorleywood, under the previous provider was good, published on 7 August 2018.

Why we inspected

This inspection was prompted by a change in the provider’s registration which meant this service did not have a current rating.

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.

Enforcement and Recommendations

We have identified a breach in relation to ensuring all people were always safe in connection to the use of oxygen therapy at this inspection. 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.