CQC report explained · a residential care home
What the CQC found at 39 School Lane
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Medicines, staffing, recruitment, infection control and risk management had improved, although some garden safety risks still needed reducing.
- Effective?
- Good
- This key question was not inspected during this focused visit. Its rating was carried forward from the previous inspection.
- Caring?
- Good
- This key question was not inspected during this focused visit. Its rating was carried forward from the previous inspection.
- Responsive?
- Good
- This key question was not inspected during this focused visit. Its rating was carried forward from the previous inspection.
- Well-led?
- Good
- The home had a clearer management structure, regular quality checks and a more open culture. People and staff were involved in developing the home and care.
What inspectors found, February 2024
Rated Good; inspectors found safer, more person-centred care, although some garden safety risks still needed attention.
This was an unannounced focused inspection on 17 January 2024. Two inspectors spoke with people, relatives, staff and a health and social care professional. They also reviewed care plans, medicines records, recruitment checks, safety records and management checks.
The home was rated Good for Safe and Well-led. Inspectors found that people were protected from abuse, medicines were managed safely, staffing levels were sufficient and the home was following the Mental Capacity Act. People were involved in decisions about their care and the running of the home.
The inspection followed a Requires Improvement rating in August 2023. The provider had been in breach of several regulations then. Inspectors found enough improvement for the home to no longer be in breach.
People's choices
People were encouraged to make their own decisions and staff used the least restrictive approach. Care plans and capacity assessments supported people's rights.
“People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests;” from the report
Safer medicines
Medicines records showed medicines were given as prescribed. Staff were trained and assessed as competent, and guidance for medicines given when needed had improved.
“People were now supported to receive their medicines safely.” from the report
Staffing and recruitment
Inspectors found enough suitable staff and safe recruitment checks. Staff received induction and worked alongside more experienced colleagues.
“The provider ensured there were sufficient numbers of suitable staff.” from the report
Better leadership
The provider had introduced regular checks, action plans and a learning culture. People and staff said their views were listened to.
“The provider now had a clear management structure that monitored the quality of care to drive improvements in service delivery.” from the report
Garden safety
needs fixingInspectors found that equipment and stored items in the garden could still create avoidable risks. The registered manager said this would be addressed without delay.
“There was no evidence of harm to people, but we found some risks could be further reduced. This included in relation to the equipment and storage of items in the garden area.” from the report
Staff vacancies
minorThe home had recent staff vacancies, although inspectors found there were enough staff at the time of the visit. New staff were due to start.
“The leadership at the home were being supported by the provider to progress recent staff vacancies and new staff were due to commence employment.” from the report
- 01Has the equipment and storage in the garden now been checked and made safe?
- 02How many staff vacancies are still open, and how are people's needs covered while new staff start?
- 03How are checks on medicines, incidents and care quality recorded and followed up?
- 04How will people continue to be involved in their care plans and decisions about the home?
- 05What were the ratings for Effective, Caring and Responsive at the previous inspection, and are any further improvements planned?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried forward from the previous inspection. This explanation was written from the published report of 14 February 2024 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, August 2023
39 School Lane was rated Requires Improvement; inspectors found risks around safeguarding, medicines, staffing and management oversight.
This was a focused inspection after information about an incident that may have put someone at risk of avoidable harm. Inspectors visited unannounced on 28 November 2022 and returned on 1 December 2022. They spoke with people using the service and staff, and checked care, medicines, staffing and management records.
Inspectors found people were not always protected from abuse. Medicines records were not always clear or complete, and some staff were working very long shifts. Mental capacity assessments did not contain enough detail, which could affect decisions about medicines, money and restrictions.
The provider's checks had not found all these problems. After inspectors raised concerns, the provider removed staff alleged to have taken part in abuse, arranged medicines reviews, brought in external auditing and changed the management arrangements. The overall rating fell from Good at the previous inspection to Requires Improvement.
Staff knew people well
People said they felt comfortable with staff, and inspectors saw that staff knew how people preferred to be supported.
“People told us they knew staff well and felt comfortable with them.” from the report
Positive behaviour support
People had support plans describing triggers and ways to respond. Staff knew where to find this guidance, and records showed it had been effective.
“People had positive behaviour support plans in place, which had been developed once staff knew people.” from the report
Clean environment
Inspectors found the home clean, with suitable infection control arrangements and secure storage for medicines.
“The service was clean and free from malodours. Environmental checks were being completed.” from the report
Family involvement
People were consulted about their care, and relatives were informed about accidents and incidents and the action taken.
“Relatives were informed of accidents and incidents as well as any actions taken.” from the report
Safeguarding was not effective
seriousStaff had received safeguarding training but did not recognise or report actions that could endanger people. The provider acted after inspectors raised the concerns.
“People were not protected from the risk of abuse.” from the report
Medicines records
seriousSome medicines instructions were unclear, and records did not show what happened before or after mood-altering medicines were given. This created a risk of overmedication or ineffective treatment.
“This meant the provider could not be assured people were receiving their medicine appropriately.” from the report
Excessive staff hours
seriousThere were enough staff at the times checked, but some staff worked 15-hour shifts and more than 60 hours a week regularly. This increased the risk of harm to people and staff.
“Several staff were working in excess of 60 hours per week on a regular basis.” from the report
- 01What changes have you made to prevent abuse, and how do you check that staff recognise and report safeguarding concerns?
- 02How are medicines given as required now recorded, including the person's behaviour before and response after the medicine?
- 03How do you prevent staff from working 15-hour shifts or more than 60 hours a week?
- 04Have all mental capacity assessments been rewritten for each specific decision about medicines, money and restrictions?
- 05What did the external audit find, and can you show us which actions have been completed and checked?
This was a focused inspection of Safe and Well-led only; the other key-question ratings were carried forward from the previous inspection. This explanation was written from the published report of 5 August 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of 39 School Lane
3 rated inspections over 2 years: the service has held its Good rating throughout.
- February 2024Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2023Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- October 2021GoodSafe: GoodWell-led: Good
- August 2020
Registered with the Care Quality Commission on 5 August 2020.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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At least 100 live-in carers within about an hour of Warwickshire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £950 to £1,260 a week. 77 can care for a couple. 11 years' experience on average.
“If you bump into her in the night on her way to the bathroom she will still inquire how you are and if everything is alright.”
“I have never met a person who is so kind and thinks about others before himself to such an extent as Chris Malagala.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.