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CQC report explained · a residential care home, run by Maria Mallaband Care Group

Mary Chapman Court

Mary Chapman Close, Dussindale, Norwich, NR7 0UD

Goodpublished 8 November 2023, 2 years ago

Rated Good: inspectors found the service performing well and meeting their expectations.

The five questions inspectors ask
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.
The latest report, explained

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.

What inspectors praised
  • 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
What inspectors were concerned about
  • Medicines records

    serious

    The 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

    serious

    Inspectors 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 fixing

    Staff 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

    minor

    Most 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
Questions to ask them, based on this report
  1. 01How do you now record the reason whenever an 'as needed' medicine is given?
  2. 02What checks are in place for cream storage and recording where pain patches are applied?
  3. 03How do you review staffing levels against people's needs, and how are vacancies covered?
  4. 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.

The story over the years

Every inspection of Mary Chapman Court

3 rated inspections over 7 years: the service has improved, from Requires improvement to Good.

  1. November 2023Goodcurrent ratingstayed Good
    Safe: GoodEffective: GoodCaring: OutstandingResponsive: GoodWell-led: Good

    Read what inspectors found at Mary Chapman Court

  2. November 2017Goodup from Requires improvement
    Safe: GoodWell-led: Good

    We are reading this report · the original is on cqc.org.uk

  3. August 2016Requires improvement
    Safe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement

    Read this report on cqc.org.uk

  4. February 2014

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  5. January 2013

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  6. August 2012

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  7. October 2011

    Registered with the Care Quality Commission on 14 October 2011.

Ratings and report dates from the Care Quality Commission. A service can also be visited without a new rating being published, so the timeline shows published inspections, not every contact the CQC has had with the service.

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