CQC report explained · a residential care home
What the CQC found at Chamberlaine Court
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, December 2022
Rated Requires Improvement; inspectors found progress, but ongoing risks and weak oversight meant the home remained in breach of regulations.
Inspectors visited on 10 and 14 November 2022. The first day was unannounced. They spoke with people, relatives, staff and healthcare professionals, observed care and checked care records, medicine records and management systems.
The home had improved in some areas. Skin breakdown risks were being managed, people at risk of poor nutrition or hydration were supported, and cleanliness had improved. People were also supported to make choices and care was provided in line with mental capacity law.
Important problems remained. Records and staff practice did not always manage risks linked to catheters, moving people, slings, constipation, falls and behaviour. Some people waited too long for care. Care records were sometimes incomplete, inaccurate or conflicting.
The overall rating changed from Inadequate to Requires Improvement, and the home was no longer in special measures. However, the home remained in breach of Regulation 12 and Regulation 17, and CQC said it would continue to monitor progress.
Nutrition and hydration
People who needed help to eat and drink were supported. Records showed food and drink were monitored, and action was taken when people were at risk of losing weight.
“Where people were at risk of losing weight, daily charts continuously monitored how much people had eaten.” from the report
Skin care
Risks linked to skin breakdown had been identified and managed through detailed plans that staff followed.
“People who had been assessed at risk of skin breakdown had detailed risk management plans which were being followed by staff.” from the report
Medicines
Inspectors found that medicines were received as prescribed and that staff were trained and assessed as competent to administer them.
“Processes were in place which ensured medicines were ordered, stored, administered and recorded effectively.” from the report
Improving management
The staff culture and day-to-day management had improved. Staff and healthcare professionals described the home as calmer and moving in the right direction.
“The staff culture at the home was positive and staff were working together to make the required improvements.” from the report
Risk management
seriousRisks were not always identified, assessed or monitored properly. Inspectors found concerns about catheter positioning, sling use, constipation, falls and required observations.
“Risks had not always been identified, assessed or monitored to ensure staff provided safe care and treatment.” from the report
Timeliness of care
needs fixingStaffing numbers kept people safe during the inspection, but care was not always delivered promptly. People and relatives reported long waits, and inspectors observed delays affecting dignity.
“Staffing numbers did not always ensure care was delivered in a timely way which promoted people's dignity and emotional well-being.” from the report
Quality checks
seriousThe provider's audits and checks did not reliably find or correct safety concerns. Some checks were also less consistent when the registered manager was not present.
“Systems and processes continued be ineffective at identifying areas of improvement.” from the report
Infection control
needs fixingThe home was cleaner than at the previous inspection, but staff did not always follow face mask guidance.
“We observed some occasions where staff did not follow infection control guidance and were either not wearing a facemask or wearing this under their nose when supporting people.” from the report
Eating and drinking records
seriousA person's difficulty eating and possible choking risk was not reflected in their records or passed to management for review.
“This incident should have led to a review of the person's nutritional support needs, but this information was not recorded in the person's daily notes or handed over to management.” from the report
- 01How do you now check that each person's risks, including catheter care, moving and handling, sling use, falls and constipation, are correctly recorded and followed?
- 02How will you make sure staff complete required observations and use the correct equipment for each person?
- 03What staffing levels are in place on each shift, and how do you prevent long waits for personal care or call bell responses?
- 04How do you check that care records are accurate, up to date and reviewed when a person's needs change?
- 05What action has been completed since this inspection to meet Regulations 12 and 17, and how is progress being checked?
This was a focused inspection covering Safe, Effective and Well-led; Caring and Responsive were not inspected and their previous ratings were carried over. This explanation was written from the published report of 17 December 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.
What inspectors found, July 2022
Chamberlaine Court was rated Inadequate and placed in special measures; inspectors found repeated safety, care and management failures.
This was a focused inspection on 31 May and 7 June 2022. Inspectors spoke with people, care staff and management. They reviewed care records, medicine records, accident records, audits, fire safety and infection control arrangements.
The home was not always safe. Risk assessments were out of date or unclear. Inspectors found problems with fire doors, window restrictors, cleanliness, food storage and the use of protective equipment. Call alarm records also showed more than 200 calls a month had taken over 20 minutes, although waiting times had recently reduced.
The home was rated Inadequate for Effective and Well-led. Care plans did not always reflect people's current needs. Records about food, fluids, repositioning and oral care were incomplete or conflicting. Audits had not found or fixed repeated problems, and management had been unstable.
The overall rating remained Inadequate. The home was placed in special measures because inspectors found three continuing legal breaches and said enough improvement had not been made since the previous inspection.
People generally felt safe
Most people inspectors spoke with said they were happy with their care and felt safe when staff supported them.
“People we spoke with told us they were happy with their care and support and that they felt safe when staff supported them.” from the report
Medicines practice had improved
Inspectors found improvements in medicine administration, including safer storage and recording of medicines requiring two signatures.
“At this visit we found improved practices so people received their medicines safely.” from the report
Care plans and risk assessments were unreliable
seriousRecords did not always reflect people's current needs or give staff clear instructions. Inspectors found conflicting information about moving, transferring, repositioning and oral care.
“Care plans, care plan reviews and risks associated with people's care were either not recorded, inaccurate or where not followed or consistently understood by the staff team.” from the report
Environmental and infection risks
seriousInspectors found a fire door that did not close, insecure window restrictors, dirty communal areas, uncovered or out-of-date food and staff wearing masks incorrectly.
“Communal lounges and dining rooms continued not to be thoroughly cleaned and free from food debris even after some surfaces were cleaned.” from the report
Food and fluid records were not dependable
seriousThere was no evidence of drinks being offered overnight on two of three days checked for one person. Staff also said some records were completed afterwards and might not be accurate.
“Staff told us they completed food and fluid diaries some time afterwards which meant we could not be confident those records were accurate.” from the report
Long call bell waits
needs fixingThe provider's own records showed more than 200 calls each month had taken over 20 minutes. The manager said waiting times had recently reduced after equipment was replaced.
“The provider's own call alarm audit showed in excess of 200 calls per month rang for over 20 minutes.” from the report
Repeated management failures
seriousAudits did not identify or resolve problems, including issues found at earlier inspections. The report also describes management instability and a blame culture.
“This is the fourth inspection where the home has achieved the same rating and the culture, ethos and willingness to do the right thing has not yet become embedded in everyday practice.” from the report
- 01How are you making sure every person's risk assessment and care plan reflects their current needs?
- 02What has been done to fix the fire doors, window restrictors, unsafe open rooms and food hygiene problems?
- 03How are you checking that people receive enough drinks and that food and fluid records are completed accurately at the time?
- 04What is the current average waiting time for call bells, and how many calls now wait over 20 minutes?
- 05What evidence can you show that the warning notice and the three regulation breaches have been addressed?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their previous ratings were used in calculating the overall rating. This explanation was written from the published report of 30 July 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 Chamberlaine Court
8 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- December 2022Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2022Inadequatedown from Requires improvementSafe: Requires improvementEffective: InadequateWell-led: Inadequate
- April 2022Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- December 2020Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- September 2019Goodstayed GoodSafe: GoodWell-led: Good
- August 2018Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Good
- July 2017Requires improvementdown from GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- June 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- August 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- August 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 20 January 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
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.