Chalkhill Road

Updated 14 May 2020

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 Care Act 2014.

Inspection team

The inspection team consisted of one inspector, a specialist advisor, a pharmacist to support with medicines and an Expert by Experience on the first day of the inspection. 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

Chalkhill Road is a 'care home'. People in care homes receive accommodation or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a manager registered with the CQC. 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. However, following this inspection, the registered manager applied to cancel their registration with the CQC.

Notice of inspection

This inspection was unannounced and took place on 28 February 2020.

What we did before the inspection

Before the inspection we reviewed the information, we held about the service and the service provider. We looked at the notifications we had received for this service. Notifications are information about important events the service is required to send us by law.

During the inspection

We spoke with seven people using the service. We also spoke with five members of staff including, the registered manager.

We observed interactions between staff and all the people using the service as we wanted to see if the service communicated and supported people in a way that had a positive effect on their wellbeing.

We reviewed six people's personal care records, seven staff record, staff rotas, medicine administration records and other records relating to the management of the service such as health and safety records and training records.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We also received further feedback for healthcare professionals.

Updated 14 May 2020

About the service

Chalkhill Road is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Chalkhill Road is registered to provide personal care and accommodation for up to 20 people with complex mental health needs making a transition from psychiatric wards, into the community. At the time of this inspection there were 14 people in residence.

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

People did not receive person centred care. Although there were measures to promote person-centred care, these were not implemented effectively. This was evident in several practice areas, including medicines management, management of violence and aggression, nutritional support and monitoring compliance with treatment orders. The cumulative effect of shortfalls in all these areas meant people did not receive care that met their needs.

People were not always protected from potential harm. Although there were safeguarding procedures, which were followed by sufficient qualified staff, risk assessments had not always addressed potential risks or included sufficient guidance for staff to mitigate potential risks to people. This included arrangements for medicines management, which were not satisfactory. People were at risk of not receiving correct medicines.

Quality assurance systems had not been used effectively to identify shortfalls. Although audits had been carried out in relevant areas, the service had not identified the shortfalls we found during this inspection. We also judged there was limited organisational learning. Action to tackle findings from our last inspection had not yet led to fundamental changes in practice. We found improvements were still required in medicines management and quality monitoring systems.

We observed kind and caring interactions between people and staff. However, the concerns we found at this inspection did not demonstrate a caring approach.

In as much as the key role for staff was to help people to regain independence, creative and flexible approaches needed to be adopted to motivate people, keeping in mind the variable degrees of support people required. In particular, the service needed to be mindful about this in relation to people’s medicines, nutrition and self-care, including keeping their living space clean.

We have made three recommendations about the management of complaints, person-centred care and end of life care.

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

The last rating for this service was requires improvement (published 19 February 2019). At this inspection enough improvement had not been made and the provider was still in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

We have found evidence that the provider needs to make improvements. Please see the Safe, Well-led, Responsive, Effective and Caring 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 Chalkhill Road 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 reinspection programme. If we receive any concerning information we may inspect sooner.

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and relevant authorities to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.