Chilton Croft Nursing Home is a care home registered to also provide nursing care. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The home is arranged over two floors and offered nursing care based on people's particular needs and requirements. The service provided care and support for up to 32 people. There were 31 people living at the home when we inspected on 8 June 2018.

At our last inspection we rated the service Good. At this inspection we found the evidence continued to support the rating of Good overall. Whilst we have rated the key question of Well-Led Requires Improvement. This was because we were notified earlier this year that the provider had admitted more people into the home that they are registered for. This was a breach of their conditions of registration of the home. We have written to the provider separately about this. There was no other evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

At the time of this inspection there was a registered manager in post. 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. The registered manager was also a director in the provider company. We have referred to this person as the registered provider throughout this report.

People continued to receive a good standard of care. People we spoke with told us they felt safe living at the home. Risks were assessed and safety of people was monitored by staff on an ongoing basis.

Risks to people were assessed, monitored and updated as and when necessary. Action was taken to reduce the risk of incidents and information about risks to people were documented in their care records so that staff were aware.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. People received a service that was caring. Staff knew people's needs well and were responsive and supportive.

The service had a complaints procedure which was made available to people and their relatives. People were happy living at the home and had no complaints.

People who lived at the home, relatives and staff told us the service was well led. Staff were aware of their roles and responsibilities and were well supported.

Further information is in the detailed findings below.

This unannounced inspection took place on 14 June 2016. The previous inspection, 2 November 2015, was a responsive visit and we found a breach in regulation 12. This related to equipment in use for pain relief that was not readily available and fit for purpose. At this inspection that had been put right.

Chilton Croft is a nursing home and can accommodate up to 32 people. Some people were living with dementia or had a physical disability.

The registered manager was present throughout the inspection and participated fully. 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.

People spoke highly of this service telling us that they were satisfied and happy living here. We observed staff to be kind, patient and demonstrating meaningful relationships with people. Relatives told us that the staff responded to individual health and care needs of people. They had confidence in the clinical and care staff and believed they had the skills to support their relative appropriately. We found that nursing staff had the confidence and skill to provide a good level of clinical intervention that met peoples nursing needs well. Relatives felt that any concern they raised would be addressed and gave us examples of this occurring. Our observations and review of records concurred with these views.

Staff were welcoming and hospitable to everyone who visited. They were positive about working as a team and enjoyed their jobs. Staff spoke of good fluid communication within the team. Staff were appropriately trained and supported as there was always nurses and management of the home available to them. There were known aims and values that staff worked towards. Staffing was structured appropriately with people understanding their role and responsibility.

People experienced an environment that was clean, fresh and ordered. They had access to appetising food that met their needs. People spoke highly of the food. Visiting health professionals also spoke highly of the service and commented that consent was in place. People receiving treatment understood who the health professional was and assessment and treatment options were explained. Nurses were found to have the correct clinical skills to meet people’s health needs.

Records were well kept. Care plans were very ordered and staff felt they could rely on the information contained in these records to guide them appropriately.

Management of the home was responsive to ideas and critique no matter from where this came, people, their relatives, staff, other professionals or CQC. We found that issues raised had been addressed well and had been sustained. There were systems to listen and respond as well as monitor the quality and safety of the service.

There was a Health and Safety Executive [HSE] investigation relating to a moving and handling avoidable harm death still outstanding. Matters are as yet not concluded and we await the outcome from HSE and any potential action they may take on this historic matter.

We carried out an unannounced comprehensive inspection of this service on 09 and 10 October 2014. We completed a follow up inspection on 19 February 2015. After these inspections we received concerns in relation to a visiting health professional who had concerns about end of life care. As a result we undertook a focused inspection to look into those concerns. This report only covers our findings in relation to this topic. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Chilton Croft nursing Home on our website at www.cqc.org.uk

Chilton Croft Nursing Home is registered for 32 people who require 24 hour nursing support and care. Some people who use the service also have a physical impairment and or living with dementia. This service requires a 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. The registered manager of the service was not there on the day of the inspection, but the clinical lead nurse was present.

The report specifically focuses on the aspect of the key area of ‘Caring’. This included end of life care and arrangements for expected and unexpected deaths within the service.

We found some good aspects of care with people telling us they were well cared for. We found that people were respected and their wishes were documented. People and their families were involved in the care planning process.

The arrangements for end of life care were not well developed. Plans were in place, but as yet had to come to full fruition. Equipment held to use in an emergency and end of life were not checked, readily available and fit for purpose. Out of date equipment was in place. We had not been accurately notified of a death within the home. This meant the provider was not meeting the requirements of the law.

You can see what action we told the provider to take at the back of the full version of the report.

We carried out an unannounced comprehensive inspection of this service on 09 and 10 October 2014. Breaches of legal requirements were found. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to regulations 10, 21 and 23 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Chilton Croft Nursing Home on our website at www.cqc.org.uk

Chilton Croft Nursing Home provides accommodation and nursing care for up to 32 people who require 24 hour support and care. Some people also have dementia and a physical impairment.

A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

At our last inspection on 09 and 10 October 2014 we found a lack of proactive managerial oversight which failed to ensure that risks to people’s safety and welfare were being identified and managed. The provider’s quality assurance system was not being used effectively to demonstrate where improvements to the service were needed. The provider had failed to recognise and address issues identified by us, in relation to staff recruitment, induction and training. This resulted in a failure to ensure that staff recruited were suitable to work with older people, and had the right mix of skills, experience and knowledge to meet their needs.

During this inspection we found that improvements had been made. The improvements enabled the provider to be assured that people received effective care from staff who were suitable to work with older people, and had the knowledge and skills they needed to carry out their roles and responsibilities. The provider had implemented quality assurance systems, and records showed that identified shortfalls were being addressed promptly. As a result the quality of the service had continued to improve. This enabled the provider to identify risks to people’s safety and welfare and manage them promptly and effectively.

People, their families and friends were involved in changes being made to the service. Their feedback about this service was consistently good. Communication about CQC’s findings and the key challenges facing the service had been shared in an open and transparent way with people at a recent ‘Resident and Relatives’ meeting.

This was an unannounced inspection to check that essential standards of quality and safety. Since April 2013 we have inspected this service seven times. We found major concerns and have taken action on each visit because people were at risk. Since our last inspection in February 2014 we have used our enforcement powers in relation to these failures. This visit was to ensure people living at the service were safe to remain there and if any improvements had been made.

The inspection team consisted of three inspectors. We spoke with six people who used the service, and one relative. We observed care and support in the lounge area and throughout the service over eight hours spent at the service. We looked at eight people's care records. Other records viewed included policies and procedures, medication management records, health and safety checks, satisfaction questionnaires completed by people who used the service, quality monitoring systems used by the manager and we toured most of the communal areas of the service, along with clinic areas and medication storage. 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?

Following major concerns in our previous inspections undertaken on 5 December 2013 in relation to unsafe moving and handling practices we found significant improvement in this area. Risk assessments to keep people safe when moving and handling people were detailed and contained all the information needed for staff to follow, including the correct equipment to use. Safer systems were in place for moving and handling people at Chilton Croft.

In our previous inspection undertaken on 25 February 2014 we had minor concerns in relation to the provider not having robust systems in place to address medication administration and recording errors identified within their own internal auditing processes. At this inspection we found that the systems in place for managing medication continued to be ineffective and the levels of mistakes were putting people at risk. We found that diabetes management and assessments of sore skin could be improved and were not reflecting best practice. Preventative safe practice was not being strived for in these two areas.

CQC monitors the operation of the Deprivation of Liberty Safeguards which apply to care homes. Following our concerns raised in our previous inspections we reviewed the provider’s application and use of legislation of the Mental Capacity Act (MCA) 2005, Deprivation of Liberty Safeguards (DoLS) and associated Codes of Practice. We saw that there was a policy and procedure in place to guide staff on these issues and that nine staff had received training. We continued to find inconsistent practice. We found in some cases that people’s capacity had not been fully considered within assessment and care planning arrangements and capacity assessments although started had not been completed. We saw that referrals to the local authority (who are responsible for assessing DoLs applications) were being made for some people. However the provider was unable to tell us how they were managing this area of people’s care following a recent court ruling which could potentially affect others using the service.

Is the service effective?

Care at Chilton Croft was striving to be effective. They had developed several ways of consulting people at the service through questionnaires, meetings and informing them of change with newsletters. People who used the service responded positively to these consultations. One relative told us, “My relative is very happy here. The nurse talks to us all the time. I am confident we would be informed of anything significant.”

The systems in place to regularly assess and monitor the quality and safety of the service provided were still not effective. Audits were carried out to identify shortfalls in medication practices, health and safety matters and infections control; however, the action plans in place to address identified shortfalls were not robust to ensure as far as possible that the events did not occur again. Best practice and expertise in response to older people’s conditions was not being demonstrated.

Is the service caring?

One person told us, “The staff are nice, polite and respectful. I speak to the manager and the nurse on a regular basis and they listen”. We saw that the staff interacted with people living in the service in a caring and respectful manner. People using the service told us staff were caring and met their needs. One person told us, “They treat me ever so well”. We saw care staff speaking respectfully to people, lowering themselves to the eye level of people and speaking clearly. We saw care staff offering people choice in what activities to undertake, and what drinks they preferred.

Privacy and dignity was respected when supporting people with personal care. People were covered when hoisted in communal areas, bedroom doors were closed as needed.

Is the service responsive?

People using the service were provided with the opportunity to participate in activities which interested them. People's choices were taken in to account and listened to. This included regular activities that people had requested and been consulted about. People told us that they had access when needed to medical professionals.

We found that the service was responsive to some matters that had been brought to their attention. An example being the need for a specialised sling for hoisting, pointed out by another professional. However, an example of not being responsive was the five month timescale set to review the medication policy and a lack of effective response to missing controlled drugs.

Is the service well-led?

We found the provider was working to address the issues we had previously pointed out to them. Whilst the provider was keen to put things right, they were not able to demonstrate that learning was being transferred from one area to another. For example, a keen focus had been placed upon safe systems of moving and handling and therefore people were safer in this area now, but the same approach had not been adopted on medication management. We were concerned that the provider was not able to demonstrate that they were being proactive in effectively monitoring the safety and quality of the service independently.

Our inspection of 18 December 2013 found that people were being put at risk of inappropriate or unsafe care and treatment. This was because the provider did not have an effective system in place that regularly assessed and monitored the quality of the service. Without these systems the provider had failed to identify, assess and manage the risks relating to the health, welfare and safety of the people that used the service and others. We also identified that people’s privacy and dignity was not always respected and the requirements of the Mental Capacity Act 2005 (MCA) were not being acted on.

At this follow up inspection we checked to see if the required improvements had been made, and found further evidence of a lack of leadership and management of the service. This was because the provider had failed to implement a robust quality checking system that managed risks and assured the health, welfare and safety of people who received care. This was confirmed in our discussion with a visiting health professional who told us they had been visiting the service in professional capacity over a period of about 10 years. They told us, “There is a lack of proper clinical leadership in the home, and that well trained nurses were needed”.

We found that there was a continued lack of understanding of when the legal requirements of the Mental Capacity Act 2005 should be applied. We also observed further incidents where people were not being treated with dignity and respect.

We spoke with one person who used the service. They told us, “I am very happy with my care, I feel a lot better of late and the staff are looking after me”. We spoke with two relatives during our inspection. One relative told us that this was the first home they had looked at and was “Impressed”. They commented, “Staff are very friendly, my relative is independent, and they like the food and the staff”. One relative told us “I visit weekly, and have seen an improvement in the home in the last few months; I am pleased with the care given to my relative”.

We found some improvements in the way the service manages people's medicines. But people were not fully protected against the risks associated with medicines because the provider did not have appropriate arrangements in place for the recording and safe administration of medicines.

Our inspection of 05 December 2013 found that people were not experiencing care that met their needs. This was because where people needed support to move, their care was not planned and delivered in a way that was intended to ensure their safety and welfare. We also identified that staff were not adequately trained to recognise peoples manual handling needs had changed, which placed people at risk of harm.

At this follow up inspection we checked to see if the required improvements had been made, and found further evidence that the provider had failed to properly assess people’s needs and ensure that they had been provided with the correct moving and handling equipment, that ensured their welfare and safety.

We spoke with one person who used the service who told us that they, “Felt safe” in the hoist when being moved by staff, “But not when it swings about”. They told us that, “The hoist is not that comfortable, although I understand it has to be used”. This person also told us, “The staff here are lovely and really look after me”.

We observed that people who used the service were provided with suitable and nutritious food and hydration in sufficient quantities that meet their needs. We spoke with one person who told us, “I have not really been asked about my preferences, but the food is good and the diet is healthy.” They also told us that, “Snacks are always available” and “Staff brought me food in my room when I felt unwell”. They told us that, “Staff were good, friendly, polite and respectful of their dignity”, when helping them with their personal care needs.

We saw that the ‘Residents and relative’s questionnaires’ had been completed by some relatives to gain their views about the service. All of the feedback was positive, referring to the service as ‘Excellent’ or ‘Very satisfied’. Although there were some positive comments about the quality of the service, we found that people were not always protected from the risks of inappropriate or unsafe care and treatment. We found that the leadership and management of the service had not identified risks to people using the service, which meant that their care was not always meeting their needs. This was because the provider did not have an effective system in place to identify, assess and manage the risks to the health, safety and welfare of people who used the service and others.

We saw that people’s privacy and dignity was not always respected. We found that before people received any care or treatment they were not asked for their consent and the provider had not acted in accordance with the legal requirements of the Mental Capacity Act 2005. People were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to manage medicines.

We spoke to the relative of person who used the service during our visit who told us, "We have mixed feelings about the care received by our relative. The caring is good and the carers are lovely and really do care”. However, they told us that they had complained where needed, “To get things changed”. They told us that they had asked, “Time and time again for the staff to feed our relative and not just leave them with the food”. They said that they had been told that this would, “Take away their independence".

People were not experiencing care that met their needs. We found that where people needed support to move their care was not planned and delivered in a way that was intended to ensure their safety and welfare. We found that where three people had lost weight this factor had not prompted revision of their risk assessment to ensure that manual handling equipment was still safe to use. We found that staff were not adequately trained to recognise where peoples manual handling needs had changed, which placed people at risk of harm.

We saw that people were provided with choices, about every day decisions, including food. We observed the chef discussing meal options with people, using a menu with photographs of the options available. People spoken with told us the food was good and they had plenty of options. One person commented, “Excellent home, excellent food, excellent staff”.

Overall we found that people's dignity and independence was respected. We saw one occasion where staff needed to be reminded about respecting people’s privacy. We spoke with a person visiting the service. They told us, “My relative has received nothing but kindness since day one” and “It is absolutely lovely here, the care is really good and the carers are really nice".

We saw evidence that the care was provided to people to meet their individual needs. We saw that there had been an improvement in recording information so that people were protected from the risk of malnutrition. Improvements had been made to ensure that people were being assessed appropriately with regards to their capacity in accordance with the Mental Capacity Act 2005.

We found we had to bring the providers attention to a person’s rapid weight loss and the lack of trained staff available, on duty to change a person’s catheter. Although, the provider took immediate action to address these matters and reduce the immediate impact on these people’s health and well-being, their own quality monitoring systems had failed to identify these issues.

We found that people’s dignity and independence were not always respected. We observed instances where people’s choice was not promoted during meal times. One person told us, “I have a choice for breakfast and tea but not for lunch. I don’t always know what I can have.”

We saw evidence that care provided to people did not meet their individual needs; we found evidence that people’s care had not been managed in a way that protected them from the risk of harm or further decline in their health or wellbeing.

We found that key information in the records such as risk assessments were not accurate. We found that key documents were missing from the care plans to support people’s needs.

We saw evidence that the service had used forms of restraint as a method of care to people with challenging behaviours. We found that these people were not assessed appropriately in accordance with the Mental Capacity Act 2005 Deprivation of Liberty Safeguards (MCA DOLS.)

We found that people were not protected from the risk of malnutrition and associated weight loss. We found that unplanned weight loss was not managed appropriately.

We found there was a sufficient number of staff on duty to support the needs of people using the service.

People were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to manage as required PRN medication.

During our inspection in September 2012 we found evidence that some people had not been involved in consenting to the care, treatment or support.

During our inspection in January 2013 we spoke with four people who used the service. All four people told us that they felt well cared for and that staff attended to them promptly when they had pressed their call bell. One person told us that they found the staff “Kind and considerate and nothing was too much trouble.”

People told us that they had a choice of meals and that the food was of a good standard. Everyone we spoke with said that they felt well and safe.

As part of the inspection carried out in January 2013 we examined two people's care records. We reviewed assessments completed prior to admission to the service. We also reviewed the risk assessments for both people. Both care plans had been updated since the last inspection in September 2012. This included a risk assessment for a person who required bed rails. The risk assessment was dated 9 September 2012.

A consent record was also in place that had been signed by the person’s relative. Another consent record for the use of a lap belt was seen and an up to date risk assessment and consent record was in place for this person dated September 2012. This meant that people had been consented and consulted with regard to their care and treatment.

We spoke with 10 people during this inspection. Eight people who used the service and two relatives. Two relatives were able to confirm that they had seen the plan of care and had signed this on their relative's behalf.

Both relatives spoken with confirmed that the plan of care reflected their wishes and preferences with regard to the way their relative received their care. The majority of people told us that the carers were reliable and that they appreciated the continuity of staff. We were told by five people that they considered the staff to be gentle and kind.

One person told us that the staff always came promptly when they pressed their call bell.

We were told that staff treated them with respect and consideration was given to their privacy and dignity at all times.

Two people we spoke with told us they knew how to complain and that the staff and manager were very approachable and conducted an "Open door policy."

Relatives told us that they had always found the service to be clean and tidy without any unpleasant smells.

We spoke with four people who use the service, they told us that their privacy, dignity and independence was respected and that their views on their care, treatment and support were taken into account. One person told us “The book is up there on the wall. The staff write down all the care they give me. I can read it if I want to”. Another person told us “The nurses have helped me understand my condition. We have met with the chef and we have sorted out my diet which has helped a great deal.”

The majority of people we spoke with told us their care plans were regularly reviewed and adapted in light of any changes. They also said that they were regularly asked for their feedback on the care being provided and how the home is run.

People we spoke with told us that they liked the activities on offer and said there is always something to do. One person said “There are loads of activities if you want to do them. I like the foot spa and having my nails done”. A different person told us “I do go downstairs and join in, but I love my books and like to watch telly. They let you do anything you like here. No pressure to get up or go to bed”.

Everyone we spoke with told us the staff were kind and caring and knew them well and understood their needs. One person told us, “They put my name in my new cardigan and have hung it in the wardrobe. One of the men has put my pictures up. They are kindness itself”. Another person told us “I have a special bed that has air in the mattress. They come and give me a look in the night, but I have this bell and I can ring them any time I need them”

People told us they enjoyed the food at the home and were given plenty of choice and variety at meal times. They also told us they were given the choice where they took their meals. One person said “We have a good cook. He made me something different last night, a meat pie. He then came and checked to see if I like it.” Another person told us “I love the breakfast and the supper. I’m not too fussed about having a big dinner. My children bring me fruit, but the home would give it to me if I asked”.

We spoke with four people who use the service. They told us they felt safe and trusted the manager and staff at the home. They also told us they knew how to report concerns and would speak with a member of staff or the manager if they had concerns and were confident that the matter would be dealt with in a timely manner. Everyone we spoke with told us they were treated with dignity and respect at all times. One person said “I’ve been here four or five years and have been treated well all that time. I’m confident the manager would sort out my problems, but I’ve had no need”. Another resident said “I feel completely safe here. Night or day I can ring the buzzer”.

We carried out this inspection on 09 and 10 October 2014.  This was an unannounced inspection. 

Chilton Croft Nursing Home provides accommodation for persons who require nursing or personal care for up to 32 people. Some people also have dementia and a physical impairment. There were 22 people living in the service when we inspected on 09 and 10 October 2014.

A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider. The registered manager also owns the company.

Previous inspections of this service dating back to August 2013 found the registered manager did not have systems in place that assessed and monitored the safety and quality of service. Our last inspection on 04 June 2014 found the provider had failed to implement an effective quality monitoring system. Additionally they were not meeting the requirements of the law in relation to the care and welfare of people, medication and consent to care and treatment. Following this inspection the provider sent us an action plan to tell us the improvements they were going to make.

During this inspection we looked to see if these improvements had been made. Although the registered manager had implemented a quality assurance system, this was not being used effectively. They were unable to demonstrate how they identified where improvements to the quality of the service were needed. They had failed to recognise and address issues identified by us, in relation to staff recruitment, induction and training. This resulted in a failure to ensure that staff recruited were suitable to work with older people, and had the right mix of skills, experience and knowledge to meet their needs.

We found there was a lack of proactive managerial oversight to ensure that risks to people’s safety and welfare were being identified and managed. CQC and other professionals have to point out the shortfalls in the service before improvements are made. There is an over reliance by the registered manager on a senior member of staff to make the required improvements. Other professionals who have had involvement with the service have shared their concerns with us about the ability of the registered manager to identify and sustain areas of improvement, should the senior member of staff be unavailable.

The culture of the service was not always open and transparent. Records showed that CQC reports were not discussed or commented on at relatives meetings or letters. This did not provide open and honest communication about CQC’s findings and the key challenges facing the service to those that used or are involved with it.

Improvements to the service were found in some areas. People and their relatives told us the service was a safe place to live. Staff understood and described how they could recognise various types of abuse. They  knew who to report any concerns to. There were appropriate arrangements in place to ensure people’s medicines were obtained, stored and administered safely.

Staff had good relationships with people who used the service and were attentive to their needs. Staff respected people’s privacy and dignity and interacted with people in a caring and respectful manner.

People, or their representatives, were involved in making decisions about their care. People’s care plans were reflective of their health needs and contained information about their ability to make decisions about their care and support. Where people lacked capacity, we saw that decisions had been made in their best interests. In line with recent changes to the law a number of Deprivation of Liberty Safeguards (DoLS) applications had been made to the local authority to make sure people’s legal rights were protected. These safeguards protect the rights of adults by ensuring that if there are restrictions on their freedom and liberty these are assessed by appropriately trained professionals.

People were supported to see, when needed, health and social care professionals to make sure they received appropriate care and treatment. People spoke highly about the quality of the food and the choices available. Their nutritional needs were being assessed and met.

Everyone we asked said they would be comfortable to raise any concerns with the registered manager or a senior staff member. People confirmed that where they had made comments about the service they had been kept informed of the changes made.

We found a number of breaches of the Health and Social care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of this report.