This unannounced comprehensive inspection took place on 14 and 15 June 2017. We returned to the service on 8 August 2017 as a serious safeguarding incident had been reported and we wanted to ensure the safeguarding plan was being fully implemented in order to protect people. We found that actions had been taken to protect people. There was an on-going police investigation and the registered manager and provider were fully co-operating with that investigation.

Chollacott House is a nursing home which provides nursing and personal care for a maximum of 42 people, many of whom have complex nursing needs. This includes people who have had a stroke, or who have long term medical conditions such as diabetes and dementia. The home also provides care for people convalescing or needing a short period of respite as well as people needing end of life care. Drake unit, part of Chollacott House and based on the first floor, has nine beds and provides care for people with neurological conditions such as Huntington's disease, Muscular Dystrophy, Motor Neurone Disease and head/brain injuries. 35 people were living at the service at the time of this inspection. The provider is Stonehaven (Healthcare) Ltd, and there are eight homes in the group.

The last comprehensive inspection took place on 7, 13 and 18 April 2016. At that time we found four breaches of regulations and the service was rated as ‘requires improvement.’ Concerns found related to safe care and treatment (including the management of medicines); dignity and respect; consent and quality monitoring systems. We took enforcement action in relation to the quality monitoring breach, by serving a warning notice on the provider and registered manager. This required the provider to make urgent improvements in this area by 30 September 2016. This was because the provider's quality monitoring systems were not effective. The provider submitted an action plan to show when and how improvements were to be achieved.

On 16 November and 23 November 2016 an unannounced follow up inspection was undertaken. The focus of this inspection was to follow up whether the service had met the warning notice and check on the safety of people living in the service. We found improvements had been made in relation to consent; cleanliness and infection and the management of medicines. However, two ongoing breaches of regulations were identified at this inspection relating to safe care and treatment and quality monitoring systems. We took enforcement action by issuing a condition of registration. This meant the provider had to send the Care Quality Commission (CQC) monthly reports on the actions that have been taken to ensure people were safe and appropriate care and support was provided. We also met with the provider to discuss our concerns.

Monthly reports were received by the CQC, which demonstrated action had been taken to reduce the risk of unsafe care and treatment. At this inspection we found improvements had been made and maintained since the last inspection.

The service has 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.

Quality assurance checks and audits carried out by the provider; registered manager and senior staff were in place and had been completed at regular intervals to monitor the safety and quality of the service. This was an improvement since our last inspection in November 2016, and had resulted in better outcomes for people using the service. Feedback from people using the service, those acting on their behalf, professionals and staff was positive about the management of the service.

People were positive about their experience of living at Chollacott. They said they felt

This inspection took place on 16 November and 23 November 2016 and was unannounced. Chollacott House is a nursing home which provides nursing and personal care for a maximum of 42 people, many of whom have complex nursing needs. This includes people who have had a stroke, or who have long term medical conditions such as diabetes and dementia. The home also provides care for people convalescing or needing a short period of respite as well as people needing end of life care. Drake unit has nine beds and provides care for people with neurological conditions such as Huntington’s disease, Muscular Dystrophy, Motor Neurone Disease and head/brain injuries. 36 people were being cared for at the home when we visited, one of whom was in hospital. The provider is Stonehaven (Healthcare) Ltd, and there are eight homes in the group.

The inspection was to follow up if the required improvements had been made following our last inspection on 7, 13 and 18 April 2016 when we identified four breaches of regulations, related to quality monitoring, safe care and treatment, dignity and respect and consent. We took enforcement action in relation to the quality monitoring breach, by serving a warning notice on the provider and registered manager. This required the provider to make urgent improvements in this area by 30 September 2016. This was because the provider’s quality monitoring systems were not effective, because they did not do all that was reasonably practicable to identify and mitigate risks for people. We issued requirements for the other three breaches of regulations. Previously the Care Quality Commission had identified breaches of regulations at an inspection in January 2015, two of which still had not been addressed in full at the April 2016 inspection.

Prior to this inspection, some concerns from relatives were raised with the Care Quality Commission, about people at the home falling and injuring themselves. We also received anonymous concerns about staffing levels, leading to poor care and about staff not reading or following care plans. We contacted the service to seek additional information about these concerns and spoke with the local authority, who investigated a relative’s complaint and were satisfied with the assurances received.

The week before the inspection, the service notified us about a person who had fallen and injured themselves, and needed hospitalisation. During the inspection, we received a notification about another person who had developed a pressure ulcer. This focused inspection was to follow up whether the service had met the warning notice and check on the safety of people living in the home. This report only covers our findings in relation to these topics. You can read the report from the last comprehensive inspection by selecting the 'all reports' link for Chollacott House Nursing Home on our website at www.cqc.org.uk

The service has 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.

Since the inspection in April 2016 we have received an action plan from the provider which outlined the improvements being made. The service has also worked in partnership with the local authority quality assurance and improvement team to improve their systems and processes.

Risk assessments and care plans were inconsistent in that some lacked sufficient detail on measures needed to reduce risks, for example in relation to nutrition/hydration and pressure ulcer risks.

People were at increased risk because daily records of food/fluid intake for people were poorly completed. Daily records for nine people showed they were at increased risk of malnutrition and dehydration. There were no records of any action taken

The unannounced inspection took place on 7, 13 and 18 April 2016. Our previous inspection in January 2015, found that the service had breaches in the regulations inspected of the Health and Social Care Act (2008). These related to monitoring the quality of service, medicines management, staffing, assessment, planning and delivery of care and accuracy of records. The provider sent us an action plan setting out how they had already met the breaches.

Chollacott House is a family run business. The nursing home provides nursing and personal care to a maximum of 42 people, many of whom have complex needs. Some live within the Drake Unit which accommodates people with neurological conditions. There were 35 older people resident at the beginning of the inspection.

The 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. 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. Chollacott House had a registered manager.

The service monitoring had not always led to a safe, quality service for people because the monitoring had not always identified where improvement was needed.

Medicine management had improved but some risks still remained, such as not always recording whether any allergies existed. Further improvements were made during the inspection visits.

The home was superficially clean but some equipment in regular use was stained and dirty and increased risk from cross contamination.

Personal care needs were not always met, such as two people’s finger nails being broken and dirty, which upset a person and a family member.

Some people’s clothing left them at risk, such as a broken shoe strap which could lead to a fall.

There was a programme of upgrading the premises but some environmental risks had not been identified and were not being dealt with within a quicker timescale. Some were addressed during the visit.

Some people’s legal rights were not upheld in line with the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards, such as not assessing a person’s capacity to make an important decision. People who were able to provide informed consent had that consent sought before they received care or treatment.

Staff expressed concern and kindness for people but this was not always translated to a kind and caring service where people could feel valued, such as finding out why a person was distressed.

Staffing arrangements took into account people’s assessed needs and were under regular review.

People’s dietary needs were understood and monitored. Most comments about the food were positive and there was a varied menu which was adapted to meet individual preferences.

People were protected through safe recruitment practice, staff training and supervision. Staff spoke very highly of the training they received.

People’s views were sought through regular resident and family meetings, care plan reviews and a yearly survey of opinion. Their views had been taken into account by the provider.

People had a variety of activities available to them including the use of the minibus for outings, arts and crafts, exercise and a newly developed garden area. One staff member said of the activities worker, “She makes every day special for people”.

People’s needs were assessed and planned with theirs, or their family's, involvement. Care plans related to either the personal care or health care needs of the person so the plan was clear for care and nursing staff to follow.

People felt able to take issues to the registered manager who investigated and followed through on any complaints. People and staff spoke highly of the registered and deputy managers.

We found four breaches in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (

We conducted an unannounced visit to Chollacott House Nursing Home on 25 May 2012 as part of a planned inspection. We had conversations with seven people who used the service, two people's family, a visiting health care professional, the manager, deputy manager, the nurse in charge, a senior care worker, a cook and laundry worker. We also looked at some care files and documents.

We saw that people were assisted at a pace which suited them and heard a person tell the staff how kind they were being. We were told of the choices available to people in their daily lives and how their assessment, care planning and review involved the person or a person acting on their behalf.

The manager was clearly well known to people and there were residents' meetings where people were able to express their views. A person told us that people could "come up with their complaints" and they said that the manager listens and acts on what they say, giving examples.

People looked comfortable and well cared for. They said that they had no complaints about the care provided and we saw that their personal and health care needs were being met. A visiting health care professional said they had no concerns about the care being delivered.

People told us that they felt safe at the home and that they would feel comfortable taking any concern to the manager. Staff knew how to alert any concerns which might indicate abuse had occurred.

People were complimentary about the staff and the care delivered.

We conducted an unannounced visit to Chollacott House on 15 December 2011 spending six and a half hours there. We were accompanied for three hours by an expert by experience. They are a person who, through their own experience of care delivery, spends time talking to people about their experience of receiving a service. The information they provided is included within this report.

People who use the service, their family and staff were very positive about the changes at the home. Comments included: "Back on track"; "Vast improvement", "Extremely happy with the home" and “There is more going on here now”.

We found there was improvement in the assessment, planning and delivery of the care people need. Therapeutic treatments were being delivered as planned. Health care professionals who have contact with the home were much happier about the standards of care.

People said they were kept well informed. People were supported to make decisions and consent to treatment. Where they did not have the mental ability to do this 'best interest' meetings were arranged on their behalf.

Information was kept confidentially and people's privacy and dignity upheld.

The standard of activities was very much improved. There had been four outings in the autumn and various regular activities within the home, such as a pantomime, puppet show and bell ringers.

The manager knew how to respond to concerns which might indicate abuse and had involved external professionals toward the best outcome for people where they had very complex needs. Staff training and support had improved. The home was much better organised, friendlier and more relaxed. People had confidence that they could take any concern to the manager and it would be dealt with appropriately.

Whilst the arrangement for staff numbers were more specific and based on people's individual needs, there remained some concerns about staffing numbers, based on what people told us. We also found that better medicine stock control was needed.

Few people who use the service are able to tell us their experience of being at Chollacott House, due to their frailty or condition. Of those that could some are quite satisfied. However, some people and their family are not. We were told: “The room is very, very dusty. It has not been cleaned in a long time”. Another person said he was unable to get up at the time he preferred and whilst in bed waiting he was uncomfortable.

The inspection visits took place on 13, 22 and 23 January 2015 and were unannounced.

Chollacott House is a nursing home providing nursing and personal care to a maximum of 42 people. The home is divided into the main home and Drake Unit which accommodates to a maximum of 10 people, some with neurological conditions. There were 34 people resident at the time of the inspection.

The service had 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 of Health and Social Care Act and associated Regulations about how the service is run. As the registered manager is not a registered nurse the home employed a lead clinical nurse but that person does not hold the legal responsibilities held by the registered persons.

At the last inspection on 16 May 2013 we found the home was meeting all the required standards we checked.

The assessment, planning and delivery of some people’s care were not sufficient, particularly where their needs were complex and a health condition required monitoring to promote their health. There were not sufficient nurses to adequately oversee the care and treatment of people with nursing needs.

Medicines management was not robust and the delivery of medicines was not always in accordance with people’s prescriptions. On two occasions, people’s pain relieving patches had not been changed on the correct day.

Not all risks were being managed and arrangements for communication sometimes failed; this had led to one person’s lunch being missed and another person’s blood test overlooked. One person had tried to climb over a bedrail but the information was not passed on quickly to protect them from the risk. Another person was given a flu injection at Chollacott House when they had recently been given one by a community nurse.

The arrangements for reviewing the standard of service had failed in that the safety concerns we found had not been identified by the management at the home or provider organisation. However, staff and health and social care professionals spoke of the openness and strong management approach of the registered manager.

Staff were trained and competent in delivering end of life care with dignity. Some staff felt it was what the home did best.

People were protected from abuse through the home’s safeguarding policies and procedures. Staff knew how to respond if they had any concerns which might indicate abuse had occurred. People were involved in decisions about their care and the staff understood legal requirements to make sure people’s rights were protected.

People were satisfied with the standard of food provided. The menu was varied and well balanced. The chef was knowledgeable about providing specialist diets to meet people’s individual needs and preferences.

People’s views were regularly sought and they were able to help shape the service they received. This included the food options, activities and entertainment. Complaints were investigated and followed through to people’s satisfaction where this was possible.

Staff were very happy with the training they received and the training options available to them. They spoke of feeling well supported through access to the registered manager, staff meetings and staff supervision arrangements. The staff recruitment arrangements ensured staff unsuitable to work in a care home for older people were unlikely to be recruited.

Staff were kind, friendly, treated people with respect and upheld their dignity. They spoke with passion about the care they provided and the people they cared for. One person said “The staff, from management down, are all respectful and willing to communicate without intrusion.”

We found breaches of the regulations 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 the report.