CQC report explained · a residential care home
What the CQC found at Chance Drive
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- People generally felt safe and safeguarding procedures had improved. However, incident records and care and risk records still needed further improvement, and medicine open dates were not consistently recorded.
- Effective?
- Good
- This area was not inspected during this focused visit. Its previous rating was used in the overall rating.
- Caring?
- Good
- This area was not inspected during this focused visit. Its previous rating was used in the overall rating.
- Responsive?
- Good
- This area was not inspected during this focused visit. Its previous rating was used in the overall rating.
- Well-led?
- Requires improvement
- Management systems and person-centred practice had improved, but the new digital records and incident system were still being developed. The service did not have a registered manager at the time described in the report.
What inspectors found, December 2021
Requires Improvement; inspectors found better safeguarding and more person-centred care, but records, medicines labelling and management systems still needed work.
This was an unannounced focused inspection on 14 October 2021. One inspector reviewed care, medicine and management records, spoke with people, relatives and staff, and contacted other professionals.
The home had improved since its previous inspection. People said they felt safe and were more involved in their care. Safeguarding reports, recruitment checks, complaints handling and infection control had improved. Medicines were given safely, but open dates were not always recorded.
The overall rating stayed Requires Improvement. Safe and Well-led were both rated Requires Improvement. The other three areas were not inspected during this visit, so their previous ratings were used. The home was no longer in breach of the regulations mentioned from the previous inspection, but CQC still required further improvement.
People felt safe
People and relatives told inspectors they felt safe. Staff knew how to identify and report safeguarding concerns.
“People and their relatives told us they felt safe in the home.” from the report
Safer staffing
The home had improved its recruitment checks and explored gaps in employment. People said there were enough staff to meet their needs.
“People told us there were enough staff to meet their needs.” from the report
Improved involvement
Monthly key-worker meetings, feedback questionnaires and activity planning had been introduced. These changes gave people more involvement in their care.
“Monthly keyworker meetings had been introduced which involved people in their care.” from the report
Infection control
Inspectors were assured that the home was following infection control, testing, protective equipment and social distancing measures.
“We were assured that the provider was using PPE effectively and safely.” from the report
Better person-centred practice
Inspectors found improvements in the way staff recorded incidents and supported people. The report said care was more person centred than at the previous inspection.
“The manager had worked closely with staff to improve their person-centred practice.” from the report
Care records were not fully up to date
needs fixingThe new digital system had improved reviews, but some care plans and risk assessments were still being updated. The system also needed to be fully embedded.
“Continued improvement was needed to fully update people's records and fully embed the new system to ensure records continued to reflect people's current needs and risks.” from the report
Medicine dates were not always recorded
needs fixingMedicines were administered safely, but open dates were not consistently written on medicine labels. This made it harder to check how long they had been open.
“Medicines were not consistently labelled with their open dates which meant it could not easily be identified how long the medicines had been open.” from the report
Incident system had a technical problem
seriousThe digital incident system could require staff to record physical restraint even when it had not happened. The manager took action, but the system was still being developed.
“The digital record system had a technical issue which meant staff were required to tick that physical restraint had taken place (even when it had not) for the incident record to be saved.” from the report
Management was still inconsistent
needs fixingThe Well-led rating improved from Inadequate to Requires Improvement, but inspectors said leadership and management did not always support high-quality, person-centred care.
“This meant the service management and leadership was inconsistent.” from the report
- 01How do you now check that every care plan and risk assessment reflects the person's current needs?
- 02How do you make sure medicine open dates are recorded every time?
- 03Has the technical problem in the digital incident system been fixed, and how do you check that restraint records are accurate?
- 04What progress has been made against the action plan since this inspection?
- 05Who is currently managing the home, and what is the status of their CQC registration?
This was a focused inspection of Safe and Well-led only; the other ratings were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 17 December 2021 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 2021
Rated Requires Improvement overall, with Inadequate leadership; inspectors found safety and safeguarding failures despite good COVID-19 infection control.
The inspection was unannounced and took place over five days in March 2021. Inspectors spoke with people, relatives and staff, and reviewed care plans, medicines records, staff files and management records.
The home was not always safe. Risks were not always assessed or updated, some safeguarding concerns were not reported, and incidents were poorly recorded and not properly analysed. Inspectors also found that concerns raised by relatives had not always been acted on.
The overall rating fell from Good at the previous inspection in 2019 to Requires Improvement. Safe was rated Requires Improvement and Well-led was rated Inadequate. The other three areas were not inspected during this focused visit, so their previous ratings were used.
COVID-19 infection control
Inspectors found good infection prevention and control arrangements, including the use of protective equipment, testing and measures to prevent outbreaks.
“There were good infection control practices in relation to COVID-19.” from the report
Medicines checks
Medicine stock balances were correct where medicines were kept in boxes. Staff had checks of their competence in administering medicines, and PRN medicine protocols were in place.
“Where people required medicines on an 'as and when required' (PRN) basis, there were protocols in place to guide staff as to when they needed to be administered.” from the report
Partnership working
The home communicated with psychology and psychiatry professionals, and inspectors saw positive feedback from external professionals.
“This evidenced partnership working between the staff team and external professionals.” from the report
Positive progress for one person
One person was preparing to move to a more independent setting to develop life skills. They spoke positively about the staff team.
“They said they would "miss all of the team" as the staff were "good".” from the report
Risks were not kept up to date
seriousCare plans and risk assessments did not always reflect changes in people's needs. This meant staff might not have the most up-to-date information about how to keep people safe.
“Care plans and risk assessments were not always updated when people's support needs or identified risks had changed.” from the report
Safeguarding concerns were missed
seriousAllegations of abuse were not consistently reported to local safeguarding teams or investigated. Records about incidents and the use of physical or chemical restraint were also poor.
“Allegations of abuse had not been consistently reported to local authority safeguarding teams and investigated.” from the report
Incidents were not properly reviewed
seriousThe home did not analyse accidents and incidents for patterns or trends. This meant it had not considered how to reduce further incidents.
“There was no analysis of incident or accidents to identify patterns, trends or themes.” from the report
Relatives' concerns were not followed up
needs fixingRelatives said they had raised concerns about staff conduct but had not received feedback. The home also had no documented system for formal feedback from people or relatives.
“They told us their concerns had not been acted on and they had not received any feedback.” from the report
Staff injuries were not assessed
seriousStaff had continued working after sustaining injuries, including head injuries, without medical attention or a risk assessment to check whether they were fit to work.
“There were 24 incidents recorded over a five-month period where staff had sustained injuries including head injuries.” from the report
- 01How have you updated each person's care plan and risk assessment since the March 2021 inspection?
- 02How do you now report and investigate safeguarding concerns, including concerns involving another person living in the home?
- 03How do you record and review physical or chemical restraint, and how do you check that it is necessary and proportionate?
- 04How do you analyse accidents, incidents and staff injuries to prevent them happening again?
- 05How do people and relatives give formal feedback, and how will they be told what action has been taken?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 27 August 2021 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 Chance Drive
3 rated inspections over 2 years: the service has slipped, from Good to Requires improvement.
- December 2021Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Inadequate
- August 2019GoodSafe: GoodWell-led: Good
- March 2019
Registered with the Care Quality Commission on 11 March 2019.
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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