CQC report explained · a nursing home
What the CQC found at Church Farm Nursing Home at Skylarks
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found people were protected from abuse and avoidable harm. Staffing, medicines, infection control, risk records and accident reviews were judged safe.
- Effective?
- Good
- This question was not inspected during this focused visit. Its previous rating was carried forward when calculating the overall rating.
- Caring?
- Good
- This question was not inspected during this focused visit. Its previous rating was carried forward when calculating the overall rating.
- Responsive?
- Good
- This question was not inspected during this focused visit. Its previous rating was carried forward when calculating the overall rating.
- Well-led?
- Good
- Inspectors found effective audits and governance, a positive culture, good partnership working and a strong focus on improvement. There was no registered manager in post, but a consistent management team was in place.
What inspectors found, November 2022
Rated Good; a focused inspection found safe care and good leadership, while a serious injury incident remained under separate investigation.
This was an unannounced focused inspection on 14 September 2022. Inspectors looked only at Safe and Well-led, partly because of concerns about falls after a serious injury. They did not examine the circumstances of that incident.
Inspectors found people were protected from abuse and avoidable harm. There were enough staff, medicines were managed safely, records were up to date, and the home was clean and well maintained. Systems for reviewing accidents and incidents had helped reduce risks.
The home was also found to be well-led. Inspectors saw a caring culture, regular audits, staff training and work with outside health professionals. The overall rating stayed Good. Ratings for areas not inspected were carried over from the last inspection, published in February 2018.
Enough staff
Inspectors found enough staff, including for people who needed one-to-one support. People were supported at times they chose and without being rushed.
“The service had enough staff, including for one-to-one support for people where this was assessed as needed.” from the report
Good safety systems
Risks were recorded and reviewed. The home also had systems to investigate accidents and use what it learned to improve care.
“Accidents and incidents were documented and analysed regularly to assess trends and patterns.” from the report
Safe medicines management
Medicines were stored, administered and recorded safely. Staff were trained and their competence was checked.
“There was a robust system in place to ensure people were offered their medication as prescribed.” from the report
Caring culture
Inspectors found that staff put people's needs and wishes first. Staff felt supported and able to raise concerns.
“The service had a positive, caring culture. People's needs and wishes came first, and staff both told us this and demonstrated it in the way they supported people.” from the report
Active improvement
The management team used audits, complaints, outside professionals and projects to improve care and reduce risks.
“There was a strong emphasis on continuous improvement and development of the service.” from the report
Serious injury incident outside this inspection
needs fixingThe inspection followed notification of a serious injury and possible concerns about falls. Inspectors did not examine the incident itself, and said it was subject to a separate investigation.
“This incident is subject to further investigation by CQC as to whether any regulatory action should be taken.” from the report
- 01What was the outcome of the serious injury incident and the separate CQC investigation?
- 02What current checks and care plans are in place to reduce the risk of falls?
- 03Who is currently responsible for managing the home while recruitment of a registered manager continues?
- 04How are staffing levels decided for people who need one-to-one support?
- 05What changes have been made following recent complaints, accidents or incidents?
This was a focused inspection of Safe and Well-led only; the other ratings were carried over from the last inspection, published in February 2018. This explanation was written from the published report of 25 November 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, February 2018
Rated Good; inspectors found safe, kind and personalised care, but identified some gaps in risk, hygiene and record keeping.
This was a comprehensive inspection. Inspectors visited without notice on 13 December 2017 and returned with notice on 18 December 2017. They spoke with people living in the home, relatives, staff and managers. They also observed care and checked records, medicines, staff files, training, rotas, complaints and quality checks.
The home was rated Good overall and received Good ratings for Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines practice, suitable training, respectful care and support that reflected people's individual choices and needs.
There were some shortfalls. Risk assessments for a new resident did not initially describe all known risks. Inspectors also found concerns about hoisting equipment, thickener storage, hand hygiene, weekly weighing records and a late notification about a serious pressure ulcer. The manager took or agreed to take action on these issues during or after the inspection.
Staffing and response
Inspectors found enough staff to meet people's needs safely. Call bells were answered promptly.
“Throughout the day we heard the call bell ringing but it was always answered promptly.” from the report
Kind and dignified care
Staff treated people with kindness and respect. Inspectors saw discreet support that protected people's dignity.
“People were supported by staff who were caring and treated them with respect, kindness and dignity.” from the report
Personalised support
Care plans included people's histories, likes, dislikes, routines and preferred ways of receiving support. People were encouraged to make choices.
“People had care plans in place that were focused on them as individuals.” from the report
Open management
Relatives and staff said they could approach the manager. The home used audits, feedback and action plans to monitor its service.
“The service had a positive ethos and an open culture which encouraged communication and learning.” from the report
New residents' risk assessments
needs fixingA new resident's risk assessment did not explain the action staff should take to reduce an identified risk. The manager changed the interim care planning process after inspectors raised this.
“where a person had only recently moved to the service we found that risk assessments did not always reflect identified risks.” from the report
Hoisting equipment
needs fixingStaff said there was not enough hoisting equipment for the people who needed it. The home later obtained another hoist.
“There were two hoists and one stand aid available for the whole service.” from the report
Choking risk and thickeners
needs fixingSome people at risk of choking were prescribed thickener, but staff were using communal containers rather than individual tins. The manager said staff would be reminded of the correct practice.
“staff were using communal thickeners rather than individual tins for the individual it was prescribed for.” from the report
Late notification
needs fixingThe CQC was not told when a serious pressure ulcer developed. A notification was sent later, and disciplinary action was taken against the staff member responsible for the care.
“we noted that they had developed a serious pressure ulcer which we should have been notified about at the time.” from the report
- 01How do you make sure risk assessments for new residents are completed fully before or soon after they move in?
- 02How many hoists and other transfer aids are available now, and how do you check that there is enough equipment for people's needs?
- 03How do you prevent communal thickeners being used for people who have individual prescriptions?
- 04What checks now make sure staff follow hand hygiene and protective clothing procedures when changing dressings?
- 05How do you make sure people are weighed as often as their care plans require, and that serious pressure ulcers are reported promptly?
This was a comprehensive inspection covering all five CQC questions, with observations, discussions and checks of care, staff and service records. This explanation was written from the published report of 14 February 2018 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 Church Farm Nursing Home at Skylarks
3 rated inspections over 7 years: the service has held its Good rating throughout.
- November 2022Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Church Farm Nursing Home at Skylarks →
- February 2018Goodstayed GoodSafe: GoodWell-led: Good
Read what inspectors found at Church Farm Nursing Home at Skylarks →
- June 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2014
Report published without a new overall rating.
- September 2013
Registered with the Care Quality Commission on 11 September 2013.
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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