CQC report explained · a residential care home
What the CQC found at Mary Chapman Court
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm, and risks were assessed and managed. However, some medicines processes and records needed strengthening.
- Effective?
- Good
- This key question was not inspected during this visit. Its previous rating was used to calculate the overall rating.
- Caring?
- Outstanding
- This key question was not inspected during this visit. Its previous rating was used to calculate the overall rating.
- Responsive?
- Good
- This key question was not inspected during this visit. Its previous rating was used to calculate the overall rating.
- Well-led?
- Good
- The home had a clear management structure, effective quality checks and an improvement plan. Feedback was gathered and used to make changes, although some people and staff gave mixed feedback about staff.
What inspectors found, November 2023
Mary Chapman Court rated Good; inspectors found people were safe and the home was well-led, but some medicines processes needed strengthening.
This was an unannounced inspection. Inspectors visited on 09 October 2023 and the CQC medicines team visited on 17 October 2023. The inspection activity ended on 26 October 2023. They spoke with 12 people, 2 relatives and 12 staff, and reviewed care, medicines, recruitment and management records.
People told inspectors they felt safe. Risks were assessed and action was taken to reduce harm. Staff were safely recruited and trained. The home was clean, visitors were welcomed and incidents were reviewed for lessons.
There were some medicines shortfalls. Records did not always explain why medicines prescribed 'as needed' had been given. Inspectors also found issues with cream storage and recording where pain patches were applied. The registered manager acted during the inspection. Staffing levels received mixed feedback from staff, although the manager said staffing was reviewed using a dependency tool.
The overall rating was Good, with Safe and Well-led both rated Good. The other key questions were not inspected during this visit, so their previous ratings were used in calculating the overall rating.
People felt safe
People and relatives told inspectors they felt safe. Staff understood how to report safeguarding concerns.
“I feel safe and secure. I only have to ring a bell, and someone comes.” from the report
Risks were managed
Risk assessments guided staff on reducing risks, including falls. Staff also made referrals to other professionals when needed.
“Risk assessments provided information to direct staff to mitigate risk as far as possible.” from the report
Safe recruitment and training
The home checked references and DBS information when recruiting. Staff received induction and further training for their roles.
“A process was in place to ensure suitable staff were recruited safely to the service.” from the report
Quality monitoring
The home had quality checks that identified shortfalls and an improvement plan to track actions.
“A robust quality assurance system was in place which was effective in identifying shortfalls in the quality and standard of care.” from the report
Medicines records
seriousThe reason for giving some 'as needed' medicines was not consistently recorded. Inspectors also found that some guidance needed more detail, although action was taken during the inspection.
“Information relating to the reason for administration of 'as required medicines' was not consistently recorded.” from the report
Medicine storage and application
seriousInspectors found issues with the safe storage of creams and recording where pain patches were applied. The registered manager corrected these issues during the inspection.
“For example, safe storage of creams and where pain patches were applied on people's bodies.” from the report
Staffing feedback
needs fixingStaff gave mixed feedback about staffing levels. The manager said staffing was reviewed regularly using a dependency tool and that recruitment had taken place to fill vacancies.
“We received mixed feedback from staff regarding staffing levels in the home.” from the report
Mixed views about staff
minorMost feedback about staff was positive, but one person said a few staff were not as good as others. The manager said action would be taken.
“Most care staff are very good, a few a bit iffy.” from the report
- 01How do you now record the reason whenever an 'as needed' medicine is given?
- 02What checks are in place for cream storage and recording where pain patches are applied?
- 03How do you review staffing levels against people's needs, and how are vacancies covered?
- 04What action have you taken in response to mixed feedback about some staff?
This was a focused inspection of Safe and Well-led; the other key-question ratings were not inspected and previous ratings were used for the overall rating. This explanation was written from the published report of 8 November 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, November 2017
Rated Good, with Outstanding care; inspectors found safe, personalised support, but staff supervision and management arrangements needed attention.
This was an unannounced inspection on 19 September 2017. Inspectors observed care, meals, medicines and activities. They spoke with people living in the home, relatives, staff and health professionals, and checked care, medicines, staffing and other records.
The home was rated Good overall. It was rated Good for Safe, Effective, Responsive and Well-led. Caring was rated Outstanding. Inspectors found enough staff, safe medicines management, detailed care plans and good support with food, health and decision-making.
Inspectors found exceptionally kind and personalised care. People were supported to make choices, keep their independence and take part in activities that mattered to them. End of life care was also described as outstanding.
The home had improved since the previous inspection in June 2016, when it was rated Requires Improvement. Staffing, weight monitoring, medicines administration and quality checks had improved. At this inspection, the registered manager had left, and not all staff had received supervision as often as the provider's policy required.
Kind and personal care
Staff knew people well and adapted care to their preferences, communication needs and interests. People were treated with warmth and respect.
“Staff were extremely kind and compassionate. People's rights to independence, privacy and dignity were valued and respected” from the report
Excellent end of life support
The home recorded people's wishes and worked with healthcare professionals to provide comfort, dignity and appropriate support at the end of life.
“The home provided outstanding end of life care. People experienced a dignified death in line with their wishes.” from the report
Safe care arrangements
Inspectors found enough staff, suitable risk assessments and safe medicines systems. Problems identified at the previous inspection had been addressed.
“At this inspection we found sufficient improvements in all of these areas.” from the report
Meaningful activities
People could take part in activities that matched their interests, including gardening, music, church visits and individual activities in bedrooms.
“People were offered a wide range of both group and individual activities that were meaningful to them and which had a positive impact on their lives.” from the report
Staff supervision was not regular enough
needs fixingSix staff files showed only two supervision sessions in the previous year, although the provider's policy expected four. The manager had identified this and put an action plan in place.
“Not all staff had received supervision sessions in line with the provider's policy, which stated staff should receive supervision four supervisions annually.” from the report
Registered manager had left
needs fixingThe registered manager left in August 2017. An acting deputy manager was in post while an application was made for a manager to support both this home and the neighbouring nursing home.
“The registered manager had left the service in August 2017.” from the report
- 01Who is the registered manager now, and how is management shared with the neighbouring nursing home?
- 02How often do staff now receive supervision, and how do you check that this happens as planned?
- 03What staffing levels are used for the current number and needs of residents?
- 04How are people's individual interests, routines and end of life wishes recorded and kept up to date?
- 05How can relatives raise concerns, and how are complaints followed up?
This was an unannounced inspection of the overall service, covering all five CQC questions and checking improvements since the previous inspection in June 2016. This explanation was written from the published report of 29 November 2017 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. The report was longer than we could read in one go; the later sections may not be reflected.
Every inspection of Mary Chapman Court
3 rated inspections over 7 years: the service has improved, from Requires improvement to Good.
- November 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: OutstandingResponsive: GoodWell-led: Good
- November 2017Goodup from Requires improvementSafe: GoodWell-led: Good
- August 2016Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2014
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- October 2011
Registered with the Care Quality Commission on 14 October 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.
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