CQC report explained · a residential care home
What the CQC found at 69 Chartridge Lane
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks were assessed and reviewed, staffing levels had improved and medicines were being given safely by trained staff. Systems for safeguarding and learning from incidents were also in place.
- Effective?
- Good
- Staff had relevant training, regular supervision and knowledge of people's individual needs. Support plans covered health needs, choices and goals, and staff worked with health professionals.
- Caring?
- Good
- People were treated with kindness, dignity and respect. Staff supported people to make choices, develop daily living skills and maintain their independence.
- Responsive?
- Good
- People had personalised support plans, activity planners and keyworkers to review their preferences and goals. Communication plans were in place and the complaints process had improved.
- Well-led?
- Good
- Inspectors found stronger leadership, open communication and better quality checks. Staff and relatives said they felt more supported and involved.
What inspectors found, August 2023
Rated Good; the home made major improvements after an Inadequate rating and has left Special Measures, with inspectors finding kind, personalised care.
This was an unannounced follow-up inspection. Inspectors visited on 31 July 2023 and gathered further information until 9 August. They spoke with people, relatives, staff, managers and health professionals. They also observed care and checked care plans, medicines records, recruitment files, incidents and quality checks.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found better risk assessments, safer medicines practice, enough trained staff, personalised support plans and more activities based on people's choices.
The report says there had been significant changes in management and many improvements since the previous inspection. The home was previously rated Inadequate and had been in Special Measures since 10 June 2022. It was no longer in breach of regulations and was no longer in Special Measures.
Personalised support
Care and support were built around people's needs, wishes, choices and goals. Staff knew people well and helped them to remain independent.
“People received personalised care and support built around their needs and wishes.” from the report
Kind and respectful care
Inspectors observed patient and appropriate interactions. Relatives said staff were caring and kind, and people's privacy was respected.
“People received kind and compassionate care. Staff were understanding and responded well to people's needs.” from the report
Safer medicines practice
Medicines were given as prescribed. Staff had medicines training and regular competency checks, with clearer records and guidance.
“At this inspection we saw that people received their medicines as prescribed and by staff trained in the management of medicine who had their competency regularly assessed.” from the report
Improved leadership
The new management team introduced audits, regular staff support and better systems for learning from incidents. Relatives reported improved communication and renewed confidence.
“The new management had made many improvements in making the necessary changes to improve the service to good.” from the report
More meaningful activities
People were supported to take part in hobbies and activities they enjoyed, both inside and outside the home. Their achievements were recorded and celebrated.
“Staff assisted people to take part in activities and hobbies they had stated they enjoyed both inside and outside of the home.” from the report
A referral delay
needs fixingA health professional raised concern about a delay in referring one person. Inspectors saw that management had put processes in place to act on this.
“They did express some concern about a delay in referring a person. We saw during the inspection that management had put processes in place to ensure this was acted upon.” from the report
- 01How do you make sure staffing levels remain safe overnight and when staff are off sick or on leave?
- 02How often are medicines audits and staff competency checks completed now?
- 03How are health referrals tracked so that delays do not happen?
- 04How often are care plans, risk assessments and activity plans reviewed with each person and their family?
- 05How do you check that the improvements found at this inspection are being maintained?
This was an unannounced follow-up inspection covering all five key questions, with inspectors also checking infection prevention and control; they visited on 31 July and gathered information until 9 August 2023. This explanation was written from the published report of 23 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.
What inspectors found, September 2022
Rated Inadequate and placed in special measures; inspectors found serious safety, staffing and management failures.
This was an unannounced inspection. Inspectors visited on 4 and 12 April 2022, spoke with people, staff and relatives, and reviewed care records, medicines records, staff files and management records. They also gathered information remotely until 27 April 2022.
The inspectors found that people were at risk of avoidable harm. Concerns included unsafe night staffing and fire evacuation arrangements, missing or incomplete risk assessments, poor incident reporting, safeguarding concerns not being referred, and a lack of evidence that staff had the right training and medicines competence.
Care was sometimes kind and people had some choices, activities and community links. However, support was not consistently person-centred, relatives were not always involved, complaints were not handled effectively, and the provider had not completed actions promised after earlier inspections.
The overall rating fell from Requires Improvement to Inadequate. Safe and Well-led were rated Inadequate, while Effective, Caring and Responsive were rated Requires Improvement. The home was placed in special measures and CQC said it would remain under review and be re-inspected.
Kind interactions
Inspectors saw that staff were mostly kind and considerate. People appeared comfortable with staff and joined in conversations.
“Staff interactions with people was mostly kind and considerate. People were comfortable with staff and actively engaged in jovial conversations with them.” from the report
Some choice and independence
People were supported to take part in activities, go into the community and carry out everyday tasks such as cleaning their rooms and doing their laundry.
“People were able to stay in the privacy of their own rooms, as and when they wanted and actively participate in daily schedules, such cleaning their rooms and doing their own laundry.” from the report
Safe and homely environment
The home was clean, homely and well maintained. Staff understood the importance of keeping hazards clear for a person with visual impairment.
“People's care and support was provided in a safe, clean, homely and well-maintained environment.” from the report
Some individual support
Care records included some information about people's communication, preferences and interests. People were supported with activities such as college, church and family contact.
“Peoples' preferences and interests were documented in people's care records.” from the report
Fire and night staffing risks
seriousThe home sometimes had only one staff member overnight, even though a fire assessment said two staff were needed to evacuate one person safely. Some personal evacuation plans were missing, out of date or inaccurate.
“We are not assured that the actions taken by the provider were sufficient to ensure that in the event of an emergency during the night when all people were asleep and only one member of staff, that they would have the assistance to safely evacuate the premises in a timely manner.” from the report
Safeguarding and incident failures
seriousSome safeguarding concerns were not referred or investigated. Incidents were not always properly reported, reviewed or used to prevent further harm.
“People were not always kept safe from avoidable harm because safeguarding concerns had not always been referred to the relevant bodies as required by law.” from the report
Incomplete risk management
seriousRecords did not always explain risks such as choking, dehydration and significant weight loss. Referrals to health professionals were not always made promptly.
“The lack of record keeping, and staff training put the person at risk of choking.” from the report
Staff training and competence
seriousMany staff had not completed training linked to people's needs, including autism, communication, positive behaviour support and dysphagia. Evidence of medicines training and competency checks could not be found when requested.
“The provider's training matrix evidenced many areas where training had either not been delivered or had been provided many years ago.” from the report
Poor family involvement
needs fixingRelatives said they were not regularly updated or invited to care reviews. The report found limited evidence that people and those important to them were involved in care decisions.
“Relatives told us they felt the service had not kept them updated about their family member and were not involved in care reviews.” from the report
Complaints not handled effectively
needs fixingThe home did not provide its complaints policy when asked. Relatives said they did not know who to contact, and complaints were not always answered in writing or followed through.
“Complaints were not always responded to appropriately.” from the report
- 01What has changed to ensure there are always enough trained staff overnight to evacuate everyone safely?
- 02Can you show us current personal evacuation plans and risk assessments for choking, dehydration, weight loss and other known risks?
- 03How do you check that all permanent and agency staff have completed training and are competent to support each person's needs and administer medicines?
- 04How are safeguarding concerns, accidents and incidents reported, investigated and used to prevent a repeat?
- 05How will relatives be involved in care reviews, health updates, complaints and decisions about the person's goals and support?
This was an unannounced inspection covering all five key questions, with visits on 4 and 12 April 2022 and further information gathered remotely until 27 April 2022. This explanation was written from the published report of 28 September 2022 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 69 Chartridge Lane
5 rated inspections over 7 years: the service has improved, from Requires improvement to Good.
- August 2023Goodcurrent ratingup from InadequateSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2022Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- April 2020Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2017Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2016Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2014
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- May 2011
Registered with the Care Quality Commission on 4 May 2011.
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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
89 live-in carers within about an hour of Buckinghamshire
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 £1,020 to £1,300 a week. 79 can care for a couple. 13 years' experience on average.
“We can all fully relax around Nyarai and she feels like part of our family, which is no mean feat!”
“She was v competent and confident and we felt our mum was safe in her care. She supported us through a difficult time.”
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.