The Chapel House Nursing Home

Updated 19 August 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

The inspection was undertaken by two 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

The Chapel House 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. The Chapel House is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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.

At the time of our inspection there was a registered manager in post, as well as a new manager who was in the process of applying to become registered with the Commission.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed the information we had received about the service and contacted the local authority quality and commissioning teams for their feedback.

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 the registered manager (who is also the nominated individual), the manager and three other members of the staff team. We also spoke with two people who lived in the home and ten relatives, about their experience of the care provided.

We reviewed a range of records. This included four people's care records and multiple medication records. We looked at three staff files in relation to safe recruitment. A variety of records relating to the management of the service, including audits were also reviewed.

Updated 19 August 2022

About the service

The Chapel House Nursing Home is registered to provide accommodation with personal care for up to a maximum of 35 older people. There were 23 people living at the home at the time of our inspection, some of whom were living with dementia.

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

We have made a recommendation regarding the systems in place to monitor the quality and safety of the service as they were not always effective. Audits did not highlight all the issues identified during the inspection, and when issues were identified, action plans were not always created to reflect what actions would be taken. A new suite of audits had just been implemented to try and improve the governance of the service.

People received their medicines from appropriately trained staff, although records regarding the management of medicines were not always robustly maintained.

Infection prevention and control policies and procedures were in place to help reduce the risk of infections, including COVID-19. The home was clean and cleaning schedules were being further developed to help minimise any risk of infections being spread. Personal Protective Equipment was available to all staff and visitors and we observed this to be worn appropriately and there was a system in place to ensure staff were undertaking COVID-19 tests in line with current guidance. Visits to the service were carried out safely in line with current government guidance.

People and their relatives told us the home was safe. Staff were aware of safeguarding procedures and knew how to report any concerns they had. Risks to people had been assessed and were managed and there were sufficient numbers of safely recruited staff available to support people. Accidents and incidents were managed safely. Records showed that appropriate actions were taken following any accidents.

Systems were in place to ensure Deprivation of Libert Safeguards (DoLS) applications were made and managed effectively. 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.

Staff received regular supervisions and an annual appraisal and told us they felt well supported. Training was available and staff told us they were up to date with their mandatory training, although records did not always support this. Relatives told us staff had the skills to support their loved ones.

People had access to plenty of food and drinks and their nutritional needs were assessed and met, although feedback regarding meals was varied. People's health and well-being was routinely reviewed, monitored and assessed and GP's were contacted when people were unwell.

People were supported and encouraged to maintain relationships and participate in activities and events of interest to them. A new team of activity staff were in the process of being recruited to enhance the current activities available. People and their relatives knew how to raise any concerns they had and were confident they would be listened to.

Feedback from people and their relatives regarding the care provided was positive. Staff were described as kind and caring, they treated people with respect and encouraged people’s independence. People were supported to be involved in their care decisions as much as possible. Family members were also included in care planning to ensure people’s needs and preferences could be met.

Relatives told us the home was managed well and that communication had improved since the new manager came into post. They told us they were kept well informed through newsletters and meetings and were able to provide feedback about the home. Staff told us they enjoyed their jobs, liked working in the home and were well supported. They told us they would recommend it to others and would be happy for their family members to live there if they required care.

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

Rating at last inspection

This service was registered with us on 14 August 2020 and this is the first inspection.

The last rating for the service under the previous provider was outstanding (published 20 December 2017).

Why we inspected

This was a planned inspection.

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.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.