Chaxhill Hall

Updated 16 December 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

This inspection was carried out by 2 inspectors and an Expert by Experience. 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

Chaxhill Hall 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. Chaxhill Hall 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

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

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

Notice of inspection

This inspection was unannounced. Inspection activity started on 9 November 2022 and ended on 15 November 2022.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority who commission the service. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 3 people who used the service and 2 relatives when we visited the care home to gain their view of the care provided. We also gained the views of 6 relatives by telephone. We observed the care provided to people who could not talk with us. We also spoke with 6 care staff including the registered manager, a housekeeper and the maintenance person. We reviewed 4 people’s care records and records pertaining to the management of 5 people’s medicines. We reviewed 4 staff recruitment files.

We also reviewed a selection of management records pertaining to equipment and safety checks, contract/servicing records, satisfaction survey, staff discussions, a selection of audits and the provider’s visit reports. We also reviewed sections of the medicines and health and safety policies and procedures.

Updated 16 December 2022

About the service

Chaxhill Hall is a residential care home providing accommodation and personal care up to a maximum of 36 people. The service provides support to older people, some of whom live with dementia. At the time of our inspection there were 30 people using the service. People were accommodated in one adapted building.

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

Medicines had not always been administered as prescribed and processes designed to support safe medicines management had not always been followed by the staff. Although no-one had been harmed, the failure to identify shortfalls in safe practice and process, had put people at risk. During the inspection immediate action was taken to prevent further shortfalls and more frequent monitoring of staff practice was put into place to ensure correct procedures were followed.

We found since our last inspection, improvements made to several other aspects of medicines management. People told us they were provided with support to take their medicines.

The provider had made improvements in how they quality monitored the service which the registered manager had found supportive. We also found improvement to how areas of the service were audited, but also found gaps in the completion of the audits. Time was needed for these to be used more effectively so they could robustly support, an already improving system, to maintain compliance and service improvement.

Safeguarding processes had been reviewed to ensure the reporting of safeguarding concerns, to the local authority and other relevant agencies took place in a timely manner. There were now arrangements in place to ensure appropriate investigation and action took place in response to safeguarding concerns. People told us they felt safe and people’s representatives told us their relatives were looked after safely.

Improvements had been made to ensure risks to people were assessed in a timely manner and action taken to reduce these. Staff had been supported to understand their roles and responsibilities regarding risk management. A new care records system had been implemented to ensure risk assessments and associated care plans were detailed and regularly reviewed for staff reference. We observed some arrangements put into place to help people remain safe, which included the use of technology such as alarmed sensor mats and specialised equipment.

Improvement had been made to the cleaning arrangements and to infection, prevention and control practices. Staff were following national guidance regarding the use of face masks and other personal, protective, equipment (PPE) to prevent the spread of infection. People told us their bedrooms were cleaned daily and they had been supported to have Flu and COVID-19 vaccinations. There were no visiting restrictions and visitors were being supported to visit their relatives and friends safely.

Arrangements were in place to keep the environment secure and safe for people who lived with dementia. We observed staff supporting people skilfully, who sometimes became distressed due to dementia, to stay safe and regain a better state of wellbeing.

The registered manager was visible to people who used the service and their visitors. Relatives described them as ‘helpful’ and ‘easy to talk with’. Staff appreciated the support and leadership they provided and felt positive and invested in the service. Feedback was sought from relatives and people to support service improvement. Learning had been taken from past inspections, complaints, concerns raised and errors to help develop staff practice.

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.

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 requires improvement (published 25 March 2021). This is the second time the provider has been rated requires improvement. 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 regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, in respect of medicines management.

At this inspection we found the provider had made improvements and was no longer in breach of regulations in respect of safeguarding service users from abuse and improper treatment and good governance.

Why we inspected

We carried out an unannounced inspection of this service on 9 January 2021 which due to the service experiencing a COVID-19 infection outbreak concluded on 11 and 12 February 2021 and 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, safeguarding service users from abuse and improper treatment and good governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they remained in breach of legal requirements in respect of medicines management. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection those key questions were inspected, to calculate the overall rating. The overall rating for the service has remained 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 Chaxhill Hall on our website at www.cqc.org.uk.

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

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 a repeated breach in relation to safe medicines management 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.