CQC HSCA Compliance
Citygate
Gallowgate
Newcastle upon Tyne
NE1 4PA
Telephone: 03000 616161
Fax: 03000 616171
www.cqc.org.uk
Your account number: 1-206258037
Our reference: INS1-927751616
Raina Summerson
Chalgrove Care Home Limited
5-7 Westminster Road East
Branksome Park
Poole
Dorset
BH13 6JF
1 November 2013
Care Quality Commission
Health and Social Care Act 2008
Factual accuracy check
Location name: Chalgrove Care and Nursing Home
Location ID: 1-208730254
Dear Ms. Summerson
Following our recent inspection of Chalgrove Care and Nursing Home, we
have compiled a draft report which is enclosed for your information.
If you have any comments relating to any factual inaccuracies in the report,
please collate them and submit one response by 20/11/2013. You can record
your comments on the enclosed factual accuracy form.
We would prefer you to send this information to us by email, please send it to
[email protected]
If you are unable to do so, please send it by post to the address below.
It is vital that you include our reference number (INS1-927751616) in any
letter or email sent with the information.
We will review your comments and amend the report if we consider it
appropriate to do so. If we do not accept your comments we will explain why.
1
If we do not receive any comments from you by the date specified above, we
will finalise the report and publish it on our website.
If you have any questions about this letter, you can contact our National
Customer Service Centre using the details below:
Telephone: 03000 616161
Email:
[email protected]
Write to:
CQC HSCA Compliance
Citygate
Gallowgate
Newcastle upon Tyne
NE1 4PA
If you do get in touch, please make sure you quote our reference number
(INS1-927751616) as it may cause delay if you are not able to give it to us.
Yours sincerely
Jo Johnson
Compliance Inspector
2
Factual accuracy comments log for an inspection report
Please fill in all parts of this form and return by email to:
[email protected] or by post to:
CQC HSCA Compliance, Citygate, Gallowgate, Newcastle upon Tyne, NE1 4PA
Account Number:
Our reference:
Provider name:
Provider address:
Page
numbe
r
e.g. Pg
4
4
4 para 4
1-206258037
INS1-927751616
Chalgrove Care Home Limited
5-7 Westminster Road East, Branksome Park,
Poole, Dorset, BH13 6JF
Outcome Suggested changes with
explanation
e.g. change last sentence from
10 staff to 15 staff
CQC
decisi
on
CQC comments
e.g. explanation of
decision
or X
Summary/
how we
carried out
this
inspection
Change: ..... observed how people
What
people
told us..
Change: We found people did not
were being cared for and checked
how people were cared for at each
stage of their treatment and care
x
To:.....observed some aspects of
care and support for (number)
residents
Because: the inspectors did not
check how (all) people were cared
for at each stage of their treatment
and care; they observed residents
outside of their personal care and
treatment routines
experience care, treatment and
support that met their needs and
protected their rights. This was
because people’s needs were not
fully assessed and planned for and
the care and support some people
needed was not delivered.
To: We found that in the main
people experienced care, treatment
and support that met their needs
and protected their rights. We noted
2 incidents where assessments did
not demonstrate care as provided
but there was no evidence of an
adverse outcome for the service
users.
Because: 1.The report under
outcome 4 refers to one instance of
3
x
Unfortunately we are not
able to change this text
as it is automatically
generated. However, we
will add more details to
the summary. We will
add the details as to how
many people were
observed during the SOFI
observation and a general
comment about observing
people in both communal
and bedroom areas in the
summary.
We will change the
statement to reflect that
‘some’ people did not
experience care,
treatment and support
that met their needs and
protected their rights.
This was because
people’s needs were not
fully assessed and
planned for and the care
and support some people
needed was not
delivered.
care not being assessed for care that
was delivered one month prior to the
inspection and was not relevant at
the time of inspection, and refers to
one instance of a wound care plan
not being evaluated within the given
timescale; these examples are not
proportionate to the statement that
people did not receive...
4 para 5
What
people
told us..
2.Chalgrove has significant evidence
to the contrary of the outcome being
met most of the time. This is
through feedback, quality assurance
mechanisms and health outcomes
being met in the view of visiting
health professionals, care managers,
families and in recent CCG and SSD
monitoring visits.
Delete: We found people were not
We do not agree to the
requested change
because the evidence in
the report supports this
judgement and these
were the findings at the
inspection.
fully protected from the risk of
infection because appropriate
guidance had not been followed
Because: See representations
against warning notice and factual
accuracy comments below re
Outcome 8
There was no evidence that people
were not fully protected as outcomes
had been impacted by the minor
areas of shortfall in infection control
areas, or that such shortfalls were
regular or sustained.
4 para 6
What
people
told us..
Delete: People who used the
service, staff and visitors were not
fully protected against the risks of
unsafe or unsuitable premises. This
was because the provider had not
taken sufficient steps to provide care
in an environment that was safe and
adequately maintained.
Because: See representations
against warning notice and factual
accuracy comments below re
Outcome 8
This implies that the general
condition of the building, equipment,
furnishings and fittings were ill cared
for and lacking in investment. This is
4
x
x As this was repeated
breach of the regulation
we need to reflect the
standard judgement
statements used by CQC.
However, we have
amended the wording to
reflect better the
shortfalls identified to:
We found that there were
continued shortfalls in
infection control. This
meant that potentially
that people were not fully
protected from the risk of
infection because
appropriate guidance had
not been followed.
We acknowledge the
information provided and
works completed.
However, we have not
made the changes
requested because the
evidence in the report
supports this judgement
and people were not fully
protected against these
risks at the inspection.
far from accurate representation of
the investment into the home and
premises. There is no evidence that
anything to do with the premises has
had had a negative impact
Page 4
para 7
What
people
told us..
Change: We found there was not
an effective complaints system in
place. This was because people
did not know how to make
complaints and information about
complaints was not accessible
x
We do not agree to the
requested change
because the evidence in
the report supports this
judgement and these
were the findings at the
inspection.
To: We found there was an effective
complaints system in place.
Because: See below re Outcome 17
6 para 4
6 para 5
4
Change: Three people we visited in
4
To: We advised staff about the two
people we visited who had said they
were thirsty and staff attended
them; we assisted one person who
was unable to raise their cup to their
mouth.
Because: this sentence is overtly
negative and reads as if people in
the home are dying of thirst; there
have been no reports or allegations
of dehydration and no health
outcomes found to evidence that
needs not being met and impacting
on skin, weight, health etc. There is
a difference between people saying
that they are thirsty at any given
time/when asked by an inspector
and that being a continued thirst
and impacting on health and well
being outcomes.
Change: We observed a mix of
We will change to
judgement to reflect
‘some’ people.

their bedrooms told us they were
thirsty and we gave additional
support to one person who was
struggling to raise their cup to their
mouth. We advised staff about the
two other people who had said they
were thirsty
good, neutral and poor
interactions from staff towards
people. These ranged from staff
reassuring, engaging and
chatting with people to staff
5
x
Thank you for the
additional information
you have provided. We
have made the changes
suggested to: We advised
staff about the two
people we visited who
had said they were thirsty
and staff attended them.
We assisted one person
who was unable to raise
their cup to their mouth.
The original SOFI tool
was based on dementia
care mapping. SOFI 2 is
the tool that CQC now
uses to observe people.
However, this tool is not
based on dementia care
mapping but is a tool
developed by CQC and
the university of Bradford
specifically for
observation during
inspections. Therefore
the references to
dementia care mapping
are not relevant to the
SOFI observation carried
out at this inspection.
ignoring people and not
acknowledging or acting on their
requests
To: We observed a mix of
positive and neutral engagement
between people and staff
Because: SOFI is based on the
DCM8 from Braford University which
does not include the categories
referred to in the report but ranges
from positive through neutral to
negative with neutral defined as
‘alert and focussed on surroundings.
Brief or intermittent engagement’.
For two of the people we
observed we also
corroborated the
observations with care
records and discussion
with the acting manager.
Additionally, as quoted on CQC
website, (SOFI) is ‘not designed to
be used alone. It acts as one source
of evidence – in making a judgement
on compliance, the data is used only
if corroborated by other evidence -
Regardless of whether
the agency staff was new
to the home. The lack of
any communication with
the individual was a ‘poor’
interaction. Other staff
who interacted with this
individual acknowledged
them and called them by
their name.
no other evidence was obtained to
corroborate the observation that
people were being ignored
One staff member who was reported
as having no interaction through
mealtime was an agency member of
staff and new to the home; this
should be made clear. The staff
reported that inspector behaviour
made them self conscious in their
duties and we recognise that this
may have had a poorer reflection on
their care than normal. Usual
satisfaction surveys, compliments
and general feedback highlights very
positive interaction and close
relationships between what is a very
long standing and stable staff group,
and the residents and families.
6 para 6
4
Add to the sentence: People told
us that there was not much to do to
6
We acknowledge that
some staff may initially
feel uncomfortable during
observations and we use
our judgement in how we
reflect this in our analysis
of the observation.
Thank you for providing
the additional information
about your usual
satisfaction surveys and
compliments. However,
as these were not
reviewed as part of this
inspection we are not
able to reflect them in
this report.

We acknowledge that we
did not look at the care
keep them entertained. For example,
one person who chose to spend time
in their bedroom said, “You don’t get
any entertainment and you don’t get
any exercise”. Another person who
was sat in a lounge told us, “I am
usually just sat here doing nothing”.
A third person told us, “Nothing to
do all day, just sit down all day
long”.
records for these
individuals and will reflect
this in the report.
Revise: We saw one person in
We have reviewed our
inspection records and
this person was admitted
to the home on 8 October
2013 and the acting
manager checked and
confirmed the moving
and handling information
in relation to this person.
They confirmed that the
individual did not have a
breathable in situ sling.
Our records show that
they had a moving and
handling plan in place
that stated ’requires full
body hoist with medium
sling for all transfers and
add... we did/did not review these
resident’s care plan’s and found
that.... (regards social activity) and
did/did not review the homes activity
schedule and records
Because: Care plans indicate the
level of assessed need which
although of course is never exact
with regards people’s right to join in
or change their mind at any given
time would give an indication of the
person’s capacity, their health regard
level of exercise they are able to
undertake and their social and
recreational preferences. Reading
the care files of the people they
spoke with would help the inspectors
triangulate the evidence rather than
rely on what they were told by
people who they did not establish
had the capacity to speak
authoritatively about their
experience in the home.
7 para 1
4
Edwardian who was sitting on a
hoist sling in a wheelchair......
Because: a review of all people who
were resident at the home at the
time of inspection has found just two x
people who required hoisting to a
chair, one of who stayed in her
bedroom all day, the other who is
assisted up, washed and dressed
early morning and is hoisted to an
arm chair with a pressure relieving
cushion and does not sit at table as
reported. Whilst we cannot argue
the content of the report in terms of
what the inspectors were told, or
what they saw in a person’s records
regarding pressure area care, we
7
However, we do need to
reflect the views and
experience of people who
are able to tell us their
experiences of living in
Chalgrove Care and
Nursing home.
can dispute the accuracy of this
sentence as it does not apply to any
resident in Edwardian leaving us to
question the validity of this section
of the report.
7 para 3
4
Change: During the mealtime in

Edwardian we saw that people were
neither happy nor sad.
To: During the mealtime in
Edwardian we saw that people were
alert and focussed on their
surroundings
7 para 3
7 para 3
4
Because: Happy or sad is
subjective, the way in which a
person waits for their meal does not
affect outcomes for people using the
service; see also section above
(page 6 para 5) re DCM
One staff member who was reported
as having no interaction through
mealtime was an agency member of
staff and new to the home; this
should be made clear. The staff
reported that inspector behaviour
made them self conscious in their
duties and we recognise that this
may have had a poorer reflection on
their care than normal. Usual
satisfaction surveys, compliments
and general feedback highlights very
positive interaction and close
relationships between what is a very
long standing and stable staff group,
and the residents and families.
Change: The majority of the staff
4
To: staff were focussed on meal
delivery and ensuring people had
their meal and drinks in a timely
manner
Because: use of the word task
makes the sentence negative
although of course in order to
achieve a person’s outcomes a series
of tasks need to be undertaken
Change: Staff generally did not

interactions with people were task
focused on the delivery of the meal
and drinks.
speak or have a conversation with
8
x
wheelchair to mobilise’.
From discussion with the
acting manager and care
records we understood
that this person had been
admitted into one of the
step down/short stay
beds.
We have reviewed our
data and the SOFI
records and can confirm
for all but one of the time
frames that people were
in a neutral mood. We
used the terminology
neither happy nor sad as
an easy descriptor for
members of the public.
However, we can amend
the report and include
that overall people were
in a neutral mood and
further information that
‘This meant that for the
five people we observed,
there was no observable
signs of positive or
negative mood.’ This
description of a neutral
mood is taken from the
SOFI 2 training and
guidance materials.
We have removed the
word ‘task’ from the
sentence.
We acknowledge that for
some people who require
people during the meal. They did not
explain to people what they were
eating.
To: Staff assisted people to eat their
meal in peace without distracting
with unnecessary conversation.
assistance to eat who
may have swallowing
difficulties it is may not
be recommended to have
a conversation whilst
their mouth is full.
However, it is our
experience that staff and
people interact and talk
throughout meal times
including reminding
people who are
supported to eat what
they are eating.
Because: All people have menu
choices each day and generally know
what they are eating. People who
require assistance to eat require it
due to difficulties chewing and
swallowing, conversation whilst their
mouth is full in not recommended.
People using the dining room
generally know what they are eating
and do not need this explaining to
them.
Regard the report that One member
As previously indicated
we acknowledge that
staff may have initially
felt self-conscious.
of staff did not speak with the
person they were supporting and
twice during the meal they walked
off without saying anything. They
returned to the individual without
acknowledging the individual and
continued to feed them; whilst we
7 para 4
4
cannot argue what the inspector
observed, we would point out that
this person was an agency member
of staff and following feedback from
the inspectors, he was spoken with
and the agency informed that we
would not use him again.
The staff reported that inspector
behaviour made them self conscious
in their duties and we recognise that
this may have had a poorer
reflection on their care than normal.
Usual satisfaction surveys,
compliments and general feedback
highlights very positive interaction
and close relationships between
what is a very long standing and
stable staff group, and the residents
and families.
Revise: On the first day of
inspection........ We spoke with the
individual who said, “I don’t want
it”.... Fifteen minutes later we
observed a staff member supporting
the individual to eat their meal
Because: This person has capacity
to make simple decisions such as
9
Thank you for the
additional information
you have provided about
the agency worker. We
will acknowledge in the
report that this was an
agency member of staff
and that the agency had
been informed that the
home would not be using
that agency worker
again.

Thank you for further
information about this
individual and we have
revised the paragraph to
reflect this. The
paragraph is now: ‘On
the first day of inspection
one person was in bed at
whether she wants her meal or not
and is able to eat independently with
support; had she not wanted her
meal or had it been too cold as the
inspectors have reported, she would
have been fully able to tell the staff
member that she did not want it.
This does not acknowledge that
people change their mind at any
given time about what they want or
need, as is their right.
7 para 6
4
Change: We looked at two people’s
assessments, care plans and records
in detail and at specific elements of
two other people’s records including
monitoring records such as food and
fluid, repositioning and hourly
monitoring records. We saw that the
majority of people’s needs had been
assessed and planned for. The
majority of people’s plans had been
reviewed and updated as and when
their needs changed
To: clarify what is meant by ‘the
majority’. The inspector looked at
two peoples records yet found the
majority of people’s needs had been
assessed and planned for and the
10

lunchtime. They were not
sat fully upright and they
had a mashed
consistency meal on the
table in front of them. We
saw that there was
Speech and language
Therapy Assessment
guidance on the wall that
specified they must be
sat upright to eat their
meals. Fifteen minutes
later we observed a staff
member supporting the
individual to eat their
meal and they were still
not sat fully upright. We
checked the individual’s
care plan and this
identified that the person
was at high risk of
aspiration (choking) and
that the individual ‘must
be sat upright and alert
for each dietary and fluid
intake’. This meant that
the individual was placed
at risk of choking and
care was not delivered as
specified in their plan. We
spoke with staff about
this individual and they
were able to tell us about
the individual and their
care and health needs.’
We have amended the
wording to reflect that
‘overall’ those people’s
needs had been assessed
and reviewed. The report
is clear about how many
peoples’ records and the
types of records we
looked at. The judgement
about this outcome area
was not based on the
records of two people but
the culmination of all the
evidence that related to
care and welfare.
majority of people’s plans had been
7 para 6
4
reviewed. This does not reflect the
overall standards and risk of care to
nearly 60 residents.
Delete: Two staff spoken with
confirmed that they had been
providing the individual with mouth
care the previous month when they
had been unwell and not drinking
many fluids. There was not a mouth
care plan in place or was it referred
to in other plans or records to reflect
that this care had been given but
was no longer needed.
x
Thank you for confirming
that a mouth care plan
should have been in
place. We do not look at
people’s needs in
isolation and on the date
of the inspection staff
had told us that they had
been providing mouth
care.
Because: whilst a mouth care plan
should have been in place the
previous month, this is not relevant
to this inspection report as it relates
to previous care and support, not at
the time of inspection and has no
impact on the outcome for the
person; the findings of one care plan
(0.52% of care files) is not
proportionate.
8 para 1
4
Delete: This person was being
cared for on a specialist air mattress
due to them being at risk of
developing pressure sores. The air
mattress monitoring checks did not
include the individual’s weight or
what setting it should be set at. Staff
had signed the record to confirm
that they had checked the mattress.
However, it was not clear what they
had checked it against and there
was not a recent weight for the
person or a setting recorded.
Because: The resident referred to
11
We referred to the mouth
care plan as there were
mouth sponges in the
individual’s bedroom at
the time of the
inspection. We would
expect that if mouth
sponges were in use then
there should be an
assessed need and plan
in place for this. The
acting manager
acknowledged that these
should not have been in
the individual’s bedroom
if they were not in use.

In determining the level
of impact for an outcome
area we consider the full
range of evidence
gathered during the
inspection.
Thank you for providing
us with this additional
information and we have
removed this from the
report.
However, as we advised
at feedback this person
had not been weighed
since August 2013 nor
had any assessment been
undertaken to monitor
their weight. We have
now included this further
was cared for on an Invacare
Softform Active mattress which self
regulates and adjusts setting
depending on the person’s weight,
movement and position in the bed,
there is no setting control. Staff
record daily only that they have
checked the mattress is switched on
and working
8 para 5
4
Change: None of the food and fluid
monitoring records seen included a
target amount, were totalled or
reviewed. This meant that staff were
not able to assess whether people
were receiving sufficient fluids. The
acting manager took immediate
action to amend the records to
include target amounts, totals,
review and any actions required.
To: On advice, the manager
amended the fluid charts to include
a target amount so that staff can
monitor daily fluid intake
Because: Whilst fluid intake should
be monitored for some people at risk
of dehydration, the omission on the
records had no impact on the
outcomes for residents, none of
whom have suffered or been treated
for dehydration.
12
x
information in the report.
We have done so
because we had
previously summarised
this information within
the paragraph that we
have removed. The
paragraph now reads:
‘The ‘MUST’ (Malnutrition
Universal Screening Tool)
record for this individual
had been completed
monthly from their
admission in April 2013
until August 2013. During
this period the individual
had lost 10 kg in weight.
Staff told us that this was
because of the
individual’s health
condition and their
reluctance to eat and
drink. However, there
were no further records
or calculations of the
individual’s weight from
this date. This meant that
staff did not have up to
date and accurate
information about the
individual’s weight.'
We have acknowledged
in the report that the
acting manager took
immediate action. We
have not indicated that
this had any impact on
health outcomes for the
people living at the
home. We have been
clear that this meant that
staff were not able to
assess whether people
were receiving sufficient
fluids.
8 para 6
9 para 3
4
There have been no health
outcomes evidenced or noted as a
result of omission, though a risk may
be heightened. This does not
accurately reflect the outcomes for
residents in this home.
Change: People who were cared for
8
To: People who were cared for in
their bedrooms or were assessed as
needing hourly checks had
monitoring records in place.
Because: Monitoring is in place
although the absence of some
(minimal) recording has not
impacted on outcomes for people,
none of whom have pressure areas.
The outcomes and impact on
resident actual care and outcomes is
not accurately reflected.
Delete: At this inspection we found
in their bedrooms or were assessed
as needing hourly checks had
monitoring records in place. We
found there were gaps in the records
for all four people whose care we
were tracking. This meant that we
could not be sure that care had been
delivered as planned.
that some areas of the home were
not clean. Extractor fans in some
people’s bathrooms and main
bathrooms were dusty. Smoke
detectors were dusty and some
people’s bedrooms were dusty and
had not been fully vacuumed. Some
toilet raisers, commodes and toilet
brushes had not been cleaned, and
were marked and stained
Because: Whilst there was some
dust trapped in extractor fans the
other allegations have been argued
in our representations about the
warning notice which were sent to
CQC on 8th December; please note,
the Warning notice was received
prior to the draft report of the
inspection.
There is no evidence that this would
harm residents well being and health
or is reflected in the general repairs,
maintenance, investment, cleaning
of the home’s environment. This is
13
x
We have reviewed our
inspection records and
can confirm that these
records were incomplete.
As you are aware these
monitoring records were
in place based on the
assessments completed
for individual by the
home.
As the records were
incomplete, we could not
be sure that that these
people were having the
checks that they had
been assessed as
needing. Therefore the
wording will remain.
x
Thank you for the
additional information.
We have reviewed our
inspection records and
the areas in the 11
bedrooms that were not
clean included both easily
visible areas and harder
to reach areas such as
underneath beds and
behind chairs and
furniture. It is positive
that in your
representations to the
warning notice you have
now cleaned the skylight
and changed the light
switch cord. The
guidance states that: ‘all
parts of the premises
from which it provides
care are suitable for the
purpose, kept clean and
maintained in good
physical repair and
9 para 4
9 para 5
8
disproportionate and misleading in
its representation of the home based
on regular checks, feedback and
outcomes.
Delete: One person used an oxygen
8
Because: Records detail the
frequency of the filter change as
directed. At the time of inspection,
the inspectors will remember that
the nurse’s time was taken with a
medical emergency including
resuscitation in a public area
(corridor) of the home. The
attending paramedics were in the
building for up to 3 hours. With the
added pressure of the inspectors in
the building, the nurses had a lot to
manage and it wasn’t a typical day
at Chalgrove. One day’s delay in
changing the filter had no impact on
the person’s outcomes.
Change: A bath chair in Tudor was
condition;’

machine 24 hours a day. They told
us that the oxygen filter should be
changed every two weeks. We
checked and the filter was grey and
dusty. We advised the acting
manager who asked staff to change
the filter the evening of the first day
of inspection. However, the person
confirmed that was not completed
until the afternoon on second day of
the inspection. The acting manager
told us that the filter was changed
very week and recorded on the
medication administration records
and that even when changed the
filter can appear discoloured.
stained and rusty and the space
between the hoist stand and bath
was dirty and the base of the hoist
stand was rusting
To: There was evidence of an ongoing maintenance and repair
programme
Because: The underside of the
bath chair and base of hoist had
some rust which the maintenance
person repaired. Again for public
information on the standards of
accommodation and care provided at
this home this statement is
14
x
We acknowledge this and
have removed this
paragraph from the
report.
The following sentence in
the report acknowledges
that maintenance staff
were painting the rust
with specialist rust paint
on the second day of the
inspection.
9 para 6
8
misleading and disproportionate.
Delete: We found a number of
unflushed toilets which meant that
there were unpleasant odours in
those bedrooms and bathrooms.
There was an unmarked open door
on the first floor in Edwardian, there
was an unpleasant odour coming
from the cupboard and an exposed
soil pipe.
Because: People are at liberty to
use the toilets freely and
independently, they may however at
times not flush the toilet and staff
cannot be expected to follow
residents round to flush toilets.
Toilets are flushed by staff when
they come across them. Whether
flushed or not, normal use of toilets
will result in some unpleasant
odours. The unmarked door was
unlocked, not open and the soil pipe
was secured until the inspector’s
removed the plastic. This
decommissioned sluice was in the
process of being refurbished, the soil
pipe is covered and a new hopper
sluice is on order
9 para 7
8
Delete: We found that one sluice in
Edwardian was unlocked on both
days of the inspection. All other
sluices throughout the home were
locked on both days. The sluice on
second floor of Edwardian had loose
tiles and an exposed edging on the
work top. This meant that surfaces
were porous and presented an
infection control risk
Because: As no resident is at risk of
accessing the sluice rooms the
absence of locks had no impact on
outcomes for people using the
service. The HSCA Code of Practice
does not require sluice rooms to be
locked. There were no loose tiles in
the Edwardian sluice, the exposed
edging around the worktop has been
repaired.
As indicated in the evidence, all
working sluices used were locked
and in order anyway.
15

In
part
We have removed the
reference to un flushed
toilets.
We have reviewed our
inspection notes and the
soil pipe was exposed. It
was not covered in plastic
and we did not remove
any covering. When we
first looked in this
cupboard there were
bags of soiled laundry
and the soil pipe was not
visible. However, there
was a strong malodour.
We looked at the
cupboard with the acting
manager and the
exposed soil pipe was
visible and there was still
a malodour. We have
changed the wording to
unlocked rather than
open.
Thank you and we
acknowledge this and we
will remove the reference
to this in the report.
10 para
6
10 para
9
11 para
2/3
8
Change: We saw the most recent

Changes requested
made.
8
To: We saw the most recent
infection control audit had been
completed on 8 October 2013, the
day before inspection. This audit
identified concerns with pedal bins,
the sluice floor not being clean and
issues with water pressure and loose
taps. The quality manager told us
that the acting manager would
review this in order to implement
required actions.
Because: The audit was the day
before inspection, the manager does
not check audits for accuracy as this
would show little faith in the auditor,
the manager will review the audits in
order to implement the required
actions. This demonstrates that the
home has systems and processes to
pick up on daily issues or shortfalls
which may occur and need
addressing before any said shortfalls
impact on resident outcomes.
Delete: We found unnamed cans of

Thank you for this
additional information
and we have removed
the references to spray
emollient.
10
Because: The emollient is used as a
soap substitute; dispensing from the
aerosol can is no different than
dispensing from a liquid soap
dispenser; as a pressurised aerosol
nothing (bacteria) can enter the
container through the nozzle.
The inclusion of this as ‘potential;’
harm seems very picky, a theme of
this inspection process.
Delete: We found that the décor in
infection control audit had been
completed on 8 October 2013. This
audit identified concerns with pedal
bins, the sluice floor not being clean
and issues with water pressure and
loose taps. The quality manager told
us that the acting manager had not
yet reviewed this audit for accuracy
spray emollient in a toilet and
bathroom. This meant that
potentially this emollient had been
used for different people which was
an infection control risk.
some bedrooms was marked and
stained and wood work was chipped.
For example, on person’s bedroom
16
x
Thank you for providing
this additional information
and we have reflected in
the report the
wall had liquid stains splattered on
the wall and the carpet was stained.
The plaster work around some door
frames was cracked and damaged
and the quality of
some plaster repairs meant that
there were exposed cracked surfaces
refurbishment of the
home that has been
undertaken and the
investment in new
furnishing and fittings.
Because: Any marks on
paintwork/decor are due to normal
wear and tear. Plaster cracks are
inevitable in an old building and new
plasterwork is subject to ‘settling’
and There is an on-going
programme of maintenance where
minor redecoration/paint touch ups
are carried out. The tone of the
report is overtly negative and does
not recognise the huge investment
and expenditure on refurbishment
and redecoration throughout all
areas of the home which have been
commented on positively by people
and their visitors.
This is an overall damaging and
disproportionate representation of
the home as does not place this in
context of 2 years of refurbishment
and over £500k of investment.
Settling cracks and knocks to newly
painted surfaces are part of ongoing
repairs and maintenance and
evidenced as such. The home has a
high standard of fixtures, fittings and
accommodation and these shortfalls
on the day are not placed in context
and present the home to the public
as in poor repair, disarray and dirty;
this is simply untrue.
Further investment in re-carpeting
and redecoration of the remaining 3
(of 58) bedrooms not yet
undertaken continues but these have
residents in situ.
11 para
4
10
Delete: There was a hole in the
ceiling in room 35 and in the corridor
on the second floor of
Edwardian
Because: The inspectors would
have noticed the scaffolding around
the home and the builders on the
roof. The roof had leaked due to
17

Thank you for this
additional information we
have removed the
reference to this.
11 para
5
11 para
6
10
heavy rain and resulted in a small
hole in the ceiling; Agincare
immediately commissioned a team of
roofers to repair the damage. The
hole in the ceiling had no bearing on
outcomes for people living at the
home. This was short term and
current piece of work, again unfairly
reflecting the state of the home out
of any context.
Delete: Two people and two staff
x
10
Because: Whilst there was a period
of time when the bath was broken, it
was out of action for a limited time
and its repair was part of the ongoing maintenance programme. The
inspectors have reported that it was
repaired between the two days of
the inspection which is evidence in
itself that the repair was scheduled
as the engineers would not have
attended at such short notice (The
inspectors left the premises at 4pm
and arrived the following morning at
11am)
Delete: On the first day of
told us that the bath hoist in
Edwardian was not working and that
people were not able to use it.
People told us if they wanted a bath
they needed to go to Tudor to have
one and one person told us that
bath was not suitable for them. We
checked the bath with the acting
manager on the first day of the
inspection who confirmed that it had
not been working for two or three
weeks and that prior to that it had
also been broken. We saw that there
were exposed wires going into the
control panel. The bath hoist was
repaired on the second day of the
inspection
inspection we found bedroom
windows without any restrictors or
broken restrictors
Because: whilst these were fixed to
satisfy the inspection team, the
windows without restrictors did not
pose any risk to the current resident
group, none of whom were at risk of
falling from an open window due to
18
x
As detailed earlier in this
response we have a duty
to report both ongoing
and current breaches and
the lack of suitable
bathing facilities had an
impact on people living at
the home for a number of
weeks. The report
acknowledges that the
bath was repaired.
We have reflected that
the manager took
immediate action to
address this. However,
there were people living
at the home who were
independently mobile.
11 para
7
12 para
1
12 para
2
10
restricted mobility
Change: There were a number of

Thank you for clarifying
this and we have
removed this from the
report.
10
To: There were two light bulbs not
working in a corridor.
Because: a number suggests that
areas of the home were in darkness
when in fact, two bulbs from an
otherwise well lit (4 lights) corridor
were still working. Poor context in a
large home of 60 bed places.
Delete: There was cupboard in

Thank you for this
information and we have
removed this from the
report.
10
Because: A cupboard that did not
need to be locked was not locked,
this is therefore not an issue that
requires reporting. If the
maintenance person takes a little
longer to clear the cupboard for
access this is about him managing
his own time and has no impact on
outcomes for people who use the
services.
Delete: We were told by some
light bulbs not working in corridors.
This mean that some corridors
were not well lit to ensure people
could see properly
Edwardian with a sign on it ‘keep
locked shut’ and it was open. This
cupboard housed a hot water tank.
The acting manager said he had
checked with the maintenance
worker who confirmed that the
cupboard did not need to be locked
but the sign needed to be removed.
The boiler cupboard on the ground
floor in Edwardian had suitcases,
handbags and coats piled up in it.
This meant that the area was not
clear for access to maintain the
boiler
people that their taps were not
working properly. We tested a
number of taps and found that they
ran slowly and took one tap took
two minutes before the water
ran hot. The acting manager told us
staff had said they started running
the taps as soon as they went into
the bedrooms to make sure people
had hot water. They acknowledged
that there were difficulties with the
hot water system and water
19
x
The report accurately
reflects the situation in
relation to some taps in
the home.
pressure in some parts of the home.
Because: Although slow, there is
hot water available in all rooms; the
above statement therefore has no
impact on people who use services.
12 para
3
12 para
4
12 para
5
10
Delete: We found loose electrical
x
10
Because: As stated above, as a
sluice room this space had been
decommissioned and is awaiting
refurbishment; this area is not used
and is not accessed by people who
use services
Delete: Room 24 Edwardian did not
The cupboard was next
to bedrooms where
people were
independently mobile. We
walked past this
cupboard with one
person who showed us
their bedroom.
x
10
Because: At the time of inspection,
room 24 was vacant, minor repairs
and refurbishment is done on
bedrooms whilst vacant at any given
time. It was clear from the other 57
bedrooms that this is not normal
practice and to be reported on in
this way is again misleading.
Delete: We found that wardrobes
Thank you for clarifying
that this bedroom was
vacant and we will
remove this form the
report.
x
We have removed that
‘However, the quality
manager acknowledged
that these risk
assessments were not in
place’. And replaced with
‘The quality manager
acknowledged that no
one was currently at risk
and therefore did not
require assessment.
However, we noted there
were a number of people
who were independently
mobile’
sockets in an open cupboard and in
the open sluice in Edwardian.
We showed the acting manager the
open cupboard with loose socket
and exposed soil pipe
have any curtains or roller blind at
the window. This meant that the
individual in that room did not have
any way of maintaining their privacy
were not secured to walls which
meant that they could potentially
be pulled over by people. The quality
manager told us that they would
only secured to the wall for people
who were independently mobile and
based on a risk assessment.
However, the quality manager
acknowledged that these risk
assessments were not in place
Because: This has never been
raised as an issue before in any of
Agincare’s care homes. Wardrobes
will not be secured to walls unless
there is a risk to an individual. The
Quality Manager did not state that
risk assessments were not in place,
she acknowledged that no one was
currently at risk and therefore did
not require assessment.
20
12 para
6
12 para
8
10
Delete: There was a broken window
x
Thank you for this
information and we have
removed this from the
report.
10
Because: this was in a toilet
entrance/lobby area used mainly for
staff and not accessed by residents
independently. The broken pane was
a small (approx 10cm) section of a
Victorian leaded light window, the
crack in the glass did not pose a risk
to residents and has since been
replaced.
Delete: We spoke to the
x
We have removed the
following sentence ‘The
maintenance worker had
been on holiday the
previous week and told
us they had jobs to catch
up on.’
pane with sharp exposed edges in
the leaded windows in Tudor. We
advised the acting manager who
made sure that the pane was taped
up and replaced by the next day
maintenance person......had been on
holiday and had jobs to catch up on
Because: The maintenance person’s
annual leave entitlement has no
bearing whatsoever on outcomes for
people who use the service; had any
emergency repairs or maintenance
been required, Agincare Facilities
Department would have organised
this.
12 para
9
10
Change: The quality manager and
acting manager confirmed that the
last health and safety audit was
completed in March 2013. They
acknowledged that due to changes
in managers at the home it had not
been clear as to who was
responsible for completing the audits
that would have identified some of
the shortfalls. We acknowledge the
acting manager took immediate
action to prioritise the environmental
issues that presented the highest
risks to people
To: The quality manager and acting
manager confirmed that the last
health and safety audit was
completed in March 2013 and we
acknowledge the acting manager
took immediate action to prioritise
the environmental issues that
presented the highest risks to people
Because: the actions or inactions of
a previous manager are not relevant
to this inspection and the Quality
21

Changes requested
made.
13 para
1
17
Manager and Acting Manager are
fully aware that the responsibility of
the audit process is clearly defined in
the company’s Quality Management
Policy.
There were not ‘high risks’ posed by
the issues the inspectors reported
on.
Change: We spoke with the
majority of people living at the home
who were able to tell us about their
experiences. Only three people and
one relative told us they knew who
they could talk to if they were
worried about anything or had any
concerns or complaints
To: We spoke with 26 people living
at the home (50%) and three
relatives. Three of the people and
one relative told us they knew who
to talk to if they were worried about
anything or had any concerns or
complaints. The home’s complaints
procedure is provided to people on
admission to the home.
Because: The inspectors did not
speak to the majority of people, they
spoke with 50% of the people as
confirmed on the inspection report
summary (page 4) and with 3
relatives. A high percentage of
people living at the home have
cognitive and memory problems and
would easily forget they were issued
with all required documentation on
admission; one of three relatives, is
a) not proportionate and b) if the
relative is not the designated next of
kin, they would not have received
the information; Chalgrove cannot
be held accountable for
communication between families.
Complaints have been made, and it
was acknowledged that these have
been recorded and dealt with
through process, therefore it is fair
to report and assume that people do
know how to complain about the
service and that if they express any
concerns that these are raised.
Complaints procedure is also
summarised in our Statement of
22

We have changed the
paragraph to: We spoke
with 26 people living at
the home and three
relatives. Three of the
people and one relative
told us they knew who to
talk to if they were
worried about anything or
had any concerns or
complaints.
Purpose/Location details issued to all
new residents/people looking round.
13 para
2
17
Change: Complaints information
was not displayed in the home. This
meant that there was no publicised
information about raising a
comment, concern or complaint
available for people in a format that
met their needs. We were told that
complaints information was included
within people’s contracts. However,
this was within the contract and not
easily accessible. This meant that
people were not made aware of the
complaints system. This was not
provided in a format that met their
needs
To: Complaints information was not
displayed in the home but was
available to people in the Care
Services guide and location details
(statement of Purpose).
Because:
Signage at the home had been
removed due to redecoration but has
since been reposted detailing the
complaints process, this is however
posted at both entrances to which
not all resident’s have access. The
complaints process is detailed in
documentation given to people on
admission and although it is
acknowledged that some people may
forget this information it is evident
through the home’s complaints log
and audit that complaints are
received and managed in accordance
with our policy; meaning, that
people do know how to complain as
if they did not, we would not receive
such complaints. The inspectors
have reported that they reviewed
complaints received by the home
and that they found them to be fully
investigated and responded to. All
respondents to the service user
survey confirmed they knew how to
make a complaint if they were
unhappy with the service.
(Include additional rows if required)
23
x
We have amended the
paragraph to read:
‘Complaints information
was not displayed in the
home. This meant that
there was no publicised
information about raising
a comment, concern or
complaint available for
people in a format that
met their needs. We
were told that complaints
information was included
within people’s contracts,
care services guide and
location details
(statement of Purpose).
However, this was within
the contract and not
easily accessible. This
meant that people were
not made aware of the
complaints system. This
was not provided in a
format that met their
needs.’ This is because
regulation 19 (2)(a)
states: ‘bring the
complaints system to the
attention of service users
and persons acting on
their behalf in a suitable
manner and format.
Completed by (name(s))
Jo Palmer
Position(s)
Group Quality Manager
Date
19/11/13
24