Chestnut View Care Home

Chestnut View Care Home is a care home providing personal and nursing care for up to 60 people. The service provides support to people who have care needs, such as, diabetes and Parkinson’s disease. Some people were living with dementia or had deteriorating mobility. At the time of our inspection there were 42 people using the service.

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

Risks associated with people’s care were not always managed safely particularly relating to moving and handling, people who were unable to use call bells and oral health care. Other risks were managed well including wound care and people that were nutritionally at risk. Aspects of the management of medicines were not safe.

People fedback they had to wait long periods of time before their call bell was answered and this was confirmed through checking call bell records. We found staff were not always deployed effectively to ensure safe delivery of care. Parts of the service were clean and tidy however we found some aspects of infection control needed improvement.

Detailed assessments of people’s needs and preferences were not always undertaken before people moved in. Care plans also lacked information around people’s life histories and preferences. End of life care was not planned appropriately.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

People were not always treated in a caring and dignified way. However, we also observed instances where staff were kind, caring and respectful to people.

Whilst staff received training this was not always effective in ensuring good practice. We have made a recommendation on this. Staff said they felt supported. Nurses were provided with effective clinical supervisions.

There was a mixed response from people about the quality of the food. People were not always involved in decisions around the meal options.

Complaints and concerns were not always taken seriously, and changes were not always made when concerns were raised.

People and relatives were not always confident in the leadership at the service. There was a lack of robust oversight to ensure the quality of care. There were staff that felt they were not always listened to however other staff said they felt valued and supported.

The provider operated effective and safe recruitment practices when employing new staff. People had access to external health care and staff followed guidance from the professionals.

People had access to meaningful activities both inside and outside of the service.

Rating at last inspection and update

The last rating for this service was requires improvement (published 29 December 2021)

Why we inspected

The inspection was prompted in part due to concerns received about the safe care and treatment of people, infection control, staff levels and people not always being protected from abuse and neglect. A decision was made for us to inspect and examine those risks.

We have found evidence that the provider needs to make improvements. Please see the safe, effective, caring, responsive and well led sections of this report.

Enforcement and Recommendations

At this inspection we have identified breaches in relation to the safe management of risks, the deployment of staff and the management of medicine. We also identified breaches in relation to the assessment of people’s care needs, complaints not always being responded to, and people’s capacity not always being assessed. We identified concerns about people not always being treated in a caring and dignified way and the lack of robust oversight. We have made two recommendations, that the provider improves how they support people with dietary needs and that the provider reviews the assessment of staff competencies to ensure safe and effective delivery of care.

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 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.

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

Chestnut View is a care home providing nursing and personal care for a maximum of 60 older people, some of whom may be living with dementia and/or a physical disability. The home accommodated people across three floors, one of which was for people with nursing care needs and one of which specialised in providing care to people living with dementia. At the time of our inspection the service was providing care to 33 people.

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

There were sufficient staff at the service to support people with the needs. Staff were aware of the risks associated with people’s care and ensured that people were provided the most appropriate care. People received their medicines when needed. People were supported with hydration and people fed back they could have baths and showers when they wanted.

The leadership team had a strong, visible person-centred culture and were making positive steps to help people to live their lives to the fullest. Staff were valued and told us they felt supported and listened to. There was a robust system in place to assess the quality of care provided. People and relatives knew how to complain and were confident their complaints would be listened. People, relatives and staff thought the leadership of the service was effective. The management team were open in relation to feedback and made improvements as soon as they were raised by us.

Rating at last inspection

The last rating for this service was Inadequate (published 26 July 2021) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

This service has been in Special Measures since June 2021. 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 carried out an unannounced inspection of this service on 11 June 2021. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment, staff levels and oversight and audits of the service.

This inspection was carried out to follow up on action we told the provider to take at the last inspection. There are still outstanding breaches which we will follow up on in due course.

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.

The ratings from the previous five domain inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from Inadequate to Requires Improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Chestnut View Care 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.

Chestnut View is a care home providing nursing and personal care for a maximum of 60 older people, some of whom may be living with dementia and/or a physical disability. The home accommodated people across three floors, one of which was for people with nursing care needs and one of which specialised in providing care to people living with dementia. At the time of our inspection the service was providing care to 36 people.

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

There were not always enough staff deployed at the service which left people at risk. Risks associated with people’s care were not always being managed in a safe way, including people’s nutrition and hydration and cleanliness of the service. Incidents and accidents were not always followed up on to avoid the risk of reoccurrence.

People did not always have choices around their care delivery and at times were not treated with dignity and respect. People were at risk of social isolation and opportunities to take part in activities were at times limited. Although people and relatives knew how to complain, they did not always feel listened to. Complaints were not always investigated fully.

Quality assurance was not always effective. Where shortfalls in care had been identified with staff this had not been addressed robustly. The leadership needed to be more effective in ensuring staff were delivering appropriate care. The provider had failed to maintain robust oversight of the service. As a result, the level of care had deteriorated from the last inspection.

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. People had access to healthcare professionals to support them with their care. People and relatives told us that staff were kind and caring and we did see examples of this.

Rating at last inspection (and update)

The last rating for this service was Requires Improvement (published 25 June 2019) and there were multiple breaches 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 improvements had not been made and the provider remained in breach of regulations. The overall rating for the service had deteriorated from Requires Improvement to Inadequate.

Why we inspected

This was a planned inspection based on the previous 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.

We have found evidence that the provider needs to make improvements. Please see the Safe, Effective, 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 Chestnut View 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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to risks related to staffing levels, safe care being provided to people, people being at risk of social isolation, lack of activities, people being supported with adequate nutrition and hydration, and the lack of robust provider and management quality assurance at this inspection.

For requirement actions of enforcement which we are able to publish at the time of the report being published. Please see the action we have told the provider to take at the end of this report.

Follow up

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.

Chestnut View is a residential care home that provide personal and nursing care for maximum of 60 older people who may be living with dementia and or a physical disability. The home accommodated people across three separate floors, one of which was for people with nursing care needs and one which specialised in providing care to people living with dementia. At the time of our inspection the service was providing care to 47 people.

People’s experience of using this service:

People told us they felt safe living at Chestnut View. However, staff were not always visible in some parts of the home, and some people waited to get attention. Risks people faced were understood and assessed. There was some inconsistency in the way some risks were recorded and managed, and we made a recommendation about this. People received their medicines in a safe way. There was evidence of learning following professional feedback and some recent safety incidents.

People were supported by staff who had received appropriate training and induction. Staff communication was good, and people were referred to healthcare professionals in a timely way. People’s nutritional needs were met and their views about their food was sought. We made a recommendation about more support for people living with dementia to choose their meals.

People’s consent was sought before staff carried out care, but the documenting of decisions made on behalf of people who lacked mental capacity was not always in place. The service was not consistent in it approach to the requirements of the mental capacity act.

People were supported in a kind and caring way by staff and we had positive feedback from relatives about the care provided. Improvements had recently been made to ensure people had privacy and were always treated with dignity. We made a recommendation about staff engaging more with people who were nursed in bed.

People’s preferences and interests were being updated to help staff give personalised care. However, we heard that some people’s wishes were not always followed. Peoples’ wishes for the end of their life were not always known or explored. Some people wanted more stimulation and daytime activity, or to be taken out on occasions. The provider had plans to improve things for people across the home and new activities staff were just in place. Complaints and concerns were responded to.

There was no registered manager in post. Over the past few months, and following feedback, the interim management had been making changes to improve the quality of care. There was an improvement plan in place. There was a positive atmosphere in the home. Some staff and some people did report being confused about who was in charge, however. Record keeping, deployment of staff and giving personalised care needed further improvement to ensure that good and effective care was consistently in place for people. The provider demonstrated a willingness and commitment to address concerns and deliver high quality care. Improvements recently made needed to be embedded and sustained.

During this inspection we found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also made three recommendations to the provider. Details of action we have asked the provider to take can be found at the end of this report. The provider was aware of some issues and started to take actions immediately following the inspection.

Rating at last inspection:

The last inspection report was published in March 2017 and the service was rated as Good.

Why we inspected:

This was an unannounced comprehensive inspection. The inspection was brought forward from the planned schedule following information we had received. The registered manager had left in December 2018 and the local authority had found some shortfalls and concerns at their visits. The concerns had been about staff levels and competence in key areas affecting the care of people with complex needs and about a lack of dignity and respect being shown to people. We followed up on these concerns at the inspection.

Follow up:

We will request an action plan from the provider to track what they do to improve the standards of care and safety. We will monitor the progress of the improvements working alongside the provider and local authority. We will return to visit in line with our re-inspection programme. If we receive any concerning information we may inspect sooner.

Chestnut View Care Home provides nursing care and accommodation for a maximum of 60 older people who may be living with dementia and or a physical disability. They also provide respite care. Respite care is a service giving carers a break by providing short term care for a person with care needs. Accommodation is provided over three floors. The top floor is primarily for people with nursing needs, the first floor is for people living with dementia and nursing needs and the ground floor is primarily for people living with dementia. At the time of this inspection there were 55 people living at the home.

During our inspection the registered manager was present. 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.

Chestnut View Care Home was last inspected on 11 January 2016 when it was given an overall rating of ‘Requires Improvement’. No breaches of regulations were identified, however the manager at that time had only been in post for six weeks and her application to register as manager of the home had not been concluded. We made four recommendations that related to the deployment of staff, information about people who were living with dementia, record keeping and the environment. At this inspection we found that the recommendations had been acted upon.

Prior to our inspection concerns had been raised about staffing levels that we shared with Surrey County Council. When they visited the home they recommended that the staffing levels within the dementia unit be increased. The registered manager acted upon this immediately. At this inspection people’s views on staffing levels varied. However, we observed that there were sufficient staff on duty and that people received assistance and support when they needed it. Appropriate recruitment checks were undertaken before staff began work.

People said that they were treated with kindness and respect. The atmosphere in the home was calm, relaxed and friendly. People’s privacy was respected. An abundance of information was displayed around the home in different formats to help people understand choices about their care. Relatives were welcomed at the home. A dementia support group organised by the registered manager offered support to relatives of people who lived at the home.

Staff were skilled and experienced to care and support people to have a good quality of life. A training programme was in place that helped to ensure staff knowledge was current. Staff were confident about their role in keeping people safe from avoidable harm and abuse. They demonstrated that they knew what to do if they thought someone was at risk of abuse.

Risks to people’s safety were managed. Some people had been assessed as having high risk of developing pressure wounds and they had skin integrity assessments in place. We saw these people had specialist beds and pressure relieving equipment to prevent their skin becoming sore. Staff supported people to move safely from wheelchairs to armchairs using a hoist. Records were in place that confirmed that hoists and slings were checked on a regular basis along with a system to report if equipment was faulty. The registered manager had a good oversight over accidents and incidents within the home.

People said that they were happy with the medical care and attention they received and we found that people’s health and care needs were managed effectively. The medicine management in the home was safe. People said that they were happy with the choice of activities on offer. Trips out into the wider community were routinely planned for and enhanced people’s wellbeing.

The registered manager had taken appropriate steps to manage restrictions on people’s freedom. DoLS applications had been submitted to the authorising authority for people who lacked capacity and were unable to leave the home freely. Mental capacity assessments were completed for people and their capacity to make decisions had been assumed by staff unless there was a professional assessment to show otherwise.

People said that the food at the home was good. People had choice over their meals and were effectively supported to maintain a healthy and balanced diet.

There was a positive culture at the home that was supported by a registered manager who took steps to ensure this was inclusive and empowering. She was passionate about providing a quality service to people. People said they felt confident that issues and concerns would be acted upon when raised. Quality assurance systems were in place that helped ensure quality standards were maintained and legislation complied with.

Chestnut View Care Home provides nursing care and accommodation for a maximum of 60 older people who may be living with dementia and or a physical disability. They also provide respite care. (Respite care is a service giving carers a break by providing short term care for a person with care needs). Accommodation is provided over three floors. The top floor is primarily for people with nursing needs, the first floor is for people living with dementia and nursing needs and the ground floor is primarily for people living with dementia. At the time of this inspection there were 51 people living at the home.

During our inspection the manager was present. The manager had been in post since December 2015 and was in the process of submitting an application to us to be the registered manager. 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.

Chestnut View Care Home was last inspected on 31 March 2015 when it was given an overall rating of ‘Requires Improvement’. Four breaches of Regulations 11,12, 17 and 18 were identified and requirement notices were issued. These related to medicines, consent to care, staff training and support and quality assurance systems. At this inspection we found that the requirement notices were met.

Although the manager had only been in post for six weeks prior to our inspection she was aware of the areas of the service that needed to improve and had started to take action to address these. Everyone that we spoke with said that the manager was a good role model and that she was implementing and driving positive changes at the home. There had been an increase in staff meetings and people were now being encouraged to be actively involved in making decisions about the service provided. Residents and relatives meetings had also been reinstated. Quality assurance systems had been reviewed and more robust monitoring of actions needed to be taken introduced in the form of a continuous improvement plan.

People said that they felt safe and we observed that they appeared happy and at ease in the presence of staff. In the main, potential risks to people were assessed and information was available for staff which helped keep people safe. We did note that for people who lived with dementia physical and emotional risks were not always linked. We have made a recommendation about this in the main body of our report.

Robust recruitment checks were completed to ensure permanent staff were safe to support people. However, this was not the case for agency staff. We raised this with the manager and the Nominated Individual who informed us that the staff from the recruitment agency would cease to be used with immediate effect. People told us that there were, on the whole, enough staff on duty to support them at the times they wanted or needed and we observed this to be the case for the majority of our inspection. We did note that people who lived with dementia did not always receive assistance at mealtimes. We have made a recommendation about this in the main body of our report.

People said that they were happy with the medical care and attention they received and we found that people’s health and care needs were managed effectively. Medicines were managed safely at Chestnut View Care Home. People’s needs were assessed and care and treatment was planned and delivered to reflect their individual care plan. The manager showed us life story books she and the activities coordinator had been working on to reflect people’s journey so far who lived with dementia and their likes and choices. This was a work in progress and had not been shared with the wider team at the time of our inspection. We have made a recommendation about this in the main body of our report.

People said that they consented to the care they received. Mental capacity assessments were completed for people and their capacity to make decisions had been assumed by staff unless there was a professional assessment to show otherwise. We saw that least restrictive practices were being followed. However, these were not always recorded. We have made a recommendation about this in the main body of our report.

People said that the food at the home was good and that their dietary needs were met. There were separate dining rooms located on each of the floors of the home which helped promote an intimate dining experience for people. However, we found that there were inconsistencies around the choices and support for people who lived with dementia. We have made a recommendation about this in the main body of our report.

Equipment was available in sufficient quantities and used where needed to ensure that people were moved safely and staff were able to describe safe moving and handling techniques. Effort had been made to ensure the design and decoration of the home was suitable for people who lived with dementia. We were shown bathrooms that the manager had arranged to be decorated in a style that was less clinical than they previously were. The manager explained that access to the garden was also going to be improved once a planning application had been approved by the local council.

Information of what to do in the event of needing to make a complaint was displayed in the home. During our visit we observed staff assessing if people were happy as part of everyday routines that were taking place.

Staff were skilled and experienced to care and support people to have a good quality of life. New staff completed an induction programme and were provided with training and supervision after this.

People said that they were treated with kindness and respect. We observed interactions by staff to people that were warm, positive, respectful and friendly whilst remaining professional. We observed that staff routinely checked that people were happy with the support being offered. Staff understood the importance of respecting people’s privacy and dignity and of promoting independence.

People said that they were happy with the choice of activities on offer and that they were supported to maintain links with people who were important to them.

We spoke with three people who used the service, four visiting relatives and six members of staff including the acting manager. We spent time observing the interactions between staff and people because not everyone who used the service was able to directly answer our questions.

We found that action had been taken and as a result people's care and safety had improved.

People or their representative's consent had been sought and recorded regarding their care and treatment.

Care had been assessed, planned and delivered appropriately according to people's needs. People we spoke with told us the staff met their needs. One person said, 'The staff are really lovely here and they do everything that I need'. Another person said, "The staff are kind and they always help me". Relatives agreed with these positive views. One relative said, 'The staff are superb, they know X really well and look after them well. I am very happy with the care'. Another relative said, 'It is over and above what we expected'.

People had been protected against abuse or harm.

Staff had been safely recruited using a system which had ensured that all the appropriate checks had been completed.

There were enough staff to meet people's needs and the way staff worked had been changed and improved. People were having their needs met by enough qualified and experienced staff.

Staff were being supported, supervised and trained to carry out their roles to the expected standards and to meet people's needs.

There was a system for assessing and monitoring the quality of the service. Peoples' views were listened to and acted on. People who used the service, their relatives and the staff said they felt the acting manager was approachable and had made positive changes to the service.

There is no registered manager in place which is a requirement of the Health and Social Care Act 2008 (registration regulations 2009). The acting manager has applied to register with the commission.

If you wish to see the detailed evidence supporting our summary please read our full report.

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?

People were not protected from the risk of inappropriate or unsafe care. This was because the provider did not have effective systems in place to assess, plan, review and monitor the care and support provided to people who used the service. In addition the procedures to identify, assess and manage risks to the health, safety and welfare of people and care workers in relation to activities had not been used effectively.

During the two days we visited to inspect this home we spoke with four people who were directly able to answer our questions, three relatives and nine members of staff. We also spoke with the acting manager and the provider's representative. We spent time observing the care people received because the majority of people who use this service are living with dementia.

Relatives of people who used the service were confident about people's safety being maintained by the provider. One relative told us 'I have never been concerned that X has been mistreated." People told us they felt safe in the service. One person said, 'They do look after me here."

Staff did understand how to manage in the event of an emergency and they had the guidance they required to protect people in emergency situations.

Is the service effective?

People's care needs had not been assessed or planned for effectively. The staff were not always aware of people's assessed needs and this led to examples where inappropriate care was delivered.

All staff had received training to meet the needs of the people who use the service. Examples of training included infection control, the safeguarding of vulnerable adults (SOVA), safe moving and handling, and fire safety.

The staff were not always aware of people's health needs including what support people needed in relation to their oral health. The information staff required to deliver appropriate care had not been recorded for their guidance.

People told us they were able to see a doctor when they needed to. We spoke to a doctor who visited the service at least weekly and they told us that people's health needs were met. They told us that it was not clear who had responsibility for making important decisions relating to their treatment.

Is the service caring?

People were supported by kind staff. We observed kind and caring interactions between staff and people who use the service. However, we also saw staff who were assisting people with their meals who did not interact or engage people in conversation.

Relatives told us they thought the staff were excellent and tried their very best to provide a caring home.

Three members of staff said they enjoyed working at the home. Six other staff said they were fond of the people who live at the home and they knew how to provide caring ,compassionate support but they did not feel supported in their roles.

There were systems in place to ensure relatives could provide feedback to the provider about the quality of the service they received. The systems for staff to inform the provider about the quality of the service had not been used effectively.

Is the service responsive?

The service was not responsive to people's needs because the number of staff was inadequate to meet people's needs at all times. This meant that staff were still responding to people's personal care needs close to lunch time as they told us they did not have time earlier in the day.

Is the service well-led?

At the time of this inspection there was no registered manager in post. The acting manager had been employed for four months and had submitted an application to register which was being considered. Shortly after this inspection we were informed by the provider that alternative management arrangements.

Quality monitoring procedures were not effectively assessing or monitoring the quality or safety of the service.

You can see our judgements on the front page of this report.

One person said, "I am really well cared for. I can't think of anything that concerns me".

Another person told us that they were happy with how their personal care needs were met. They told us that they felt very reassured with how the care staff provided support. They said, "The staff do a really good job. They are gentle and kind and I am very happy".

We also spent time observing the interactions between staff and people who use the service in the main home and in the reminiscence unit. We found this to be positive, friendly and caring.

We spoke with staff who told us that they were very happy working in the home. They felt supported in their work, had good training and felt the management was open and supportive.

We found that the provider had taken steps to address the compliance actions set at our last inspection of the service. We found that the care planning, training and provision of safe staffing levels had all been addressed at this inspection. However, the provider could not demonstrate that appropriate steps were taken to obtain the consent of people or their representatives to care and treatment.

The feedback we received was mixed and centred around the staffing levels as an area that people felt needed to be addressed by the provider. People told us that they were happy with the care and support they received but the lack of staff meant that this support was delayed. We also observed periods of time that people did not receive the support they needed in an appropriate and timely manner.

One person said, "The staff are very good but the big thing is getting someone to help when you need them."

Another person said, " Staff are very kind and helpful, I am very happy here."

At this inspection we spent time observing the interaction between staff and people and found this to be positive and valuing. People were spoken to as individuals and staff were seen to provide guidance in support to people when they asked for support.

We also found that the care planning and assessment systems used by the home did not always reflect the needs of people or provide adequate guidance to ensure people's needs were met.