CQC report explained · a nursing home
What the CQC found at Church House Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- There were enough staff overall and medicines were managed safely. However, some people waited for help, one risk assessment did not reflect a person's needs when eating in bed, some safety checks were overdue, and MCA records were not always reviewed promptly.
- Effective?
- Good
- This key question was not inspected during this focused inspection. Its previous rating was used in the overall rating.
- Caring?
- Good
- This key question was not inspected during this focused inspection. Its previous rating was used in the overall rating.
- Responsive?
- Good
- This key question was not inspected during this focused inspection. Its previous rating was used in the overall rating.
- Well-led?
- Good
- Governance and oversight had improved. Audits and a home improvement plan were in place, although the home had experienced several management changes and some care plans still needed updating.
What inspectors found, August 2023
Church House Care Home was rated Good overall, but inspectors found that safety still Requires Improvement.
This was an unannounced, focused inspection on 21 April and 12 May 2023. Inspectors checked Safe and Well-led, spoke with people, a relative and staff, and reviewed care, medicines, recruitment and management records.
People and relatives were positive about the care. Staff were described as caring and responsive. The home was clean, medicines were managed safely, and inspectors found enough staff overall, although some people waited for help during breakfast.
The home was rated Good overall. Safe remained Requires Improvement, while Well-led improved to Good. The other three ratings were carried forward from the previous inspection. The home had improved from an overall rating of Requires Improvement, and it was no longer in breach of regulations.
Kind and responsive care
People and relatives were positive about the care and support. Staff were described as caring and responsive.
“They told us staff were caring and responsive.” from the report
People felt safe
People said they felt safe. Staff had safeguarding training and understood how to report concerns.
“People told us they felt safe living at church House.” from the report
Medicines managed safely
The home had systems for safe storage and administration of medicines. Staff administering medicines were trained and assessed as competent.
“Systems were in place to ensure medicines were administered and stored safely.” from the report
Improved oversight
Leadership and governance had improved since the previous inspection. Audits and a detailed improvement plan were being used to track work.
“A recent in-depth audit had been carried out and a detailed home improvement plan was being actioned.” from the report
People waited for help
needs fixingTwo people waited for assistance during the morning, and staff were not always present in the dining area at breakfast. Managers were reviewing staff allocation and call bell response times.
“However, during the morning period 2 people were kept waiting for assistance and staff were not always present in the dining area during breakfast.” from the report
Eating and drinking risk
seriousIn one case, a person was not supported to sit up while eating and drinking in bed. Inspectors said this increased the risk of choking, and managers took immediate action.
“However, in one example staff had not supported a person to sit-up whilst eating and drinking in bed, which increased the risk of the person choking.” from the report
Records needed faster review
needs fixingSome mental capacity records had not been added to the electronic system or reviewed after people's needs changed. The provider was recommended to improve this process.
“We recommend the provider reviews the process for keeping MCA assessments and decisions under review, to ensure any changes are responded to promptly.” from the report
Care plans needed more detail
needs fixingSome care plans did not fully reflect people's needs or recent changes. The provider had identified this and was working on updates.
“Some care plans were not fully reflective of people's needs, although staff understood people and their needs well.” from the report
- 01What has changed to make sure people are not left waiting for help during breakfast and other busy periods?
- 02How will you make sure people who eat or drink in bed are supported in the safest position?
- 03How quickly are mental capacity assessments, best-interest decisions and any DoLS needs reviewed when someone's condition changes?
- 04Which building and equipment safety checks were overdue, and have they now all been completed?
- 05How are you updating care plans so they include each person's current needs and personal preferences?
This was a focused inspection of Safe and Well-led only; the Effective, Caring and Responsive ratings were carried forward from the previous inspection. This explanation was written from the published report of 4 August 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, September 2021
Church House Care Home is rated Requires Improvement; inspectors found staffing and management weaknesses, although medicines, risk assessments and infection control were satisfactory.
The inspection took place on 27 July and 4 August 2021. It started as a targeted inspection after concerns about staffing and risk assessments. Inspectors widened it to a focused inspection of Safe and Well-led after finding concerns about safeguarding and governance.
Staff were described as committed and caring, but there were not always enough of them, especially on the lower floor. Staff were under pressure and had to decide who to help first. This meant care was at risk of becoming task-focused rather than centred on each person.
Inspectors found medicines were managed safely, risk assessments were up to date and infection control arrangements were suitable. However, safeguarding records, quality checks, staff support and management arrangements were not reliable enough.
The overall rating fell from Good to Requires Improvement. Safe and Well-led were both rated Requires Improvement. Effective, Caring and Responsive were not inspected during this visit, so their earlier ratings were carried forward.
Medicines
Medicines were securely stored, records were completed appropriately and staff who gave medicines had their competence checked.
“Medicines were securely stored with medicine administration records completed appropriately.” from the report
Risk assessments
Assessments covered people's health, nutrition, skin care and emergency evacuation needs. Environmental and equipment checks were also up to date.
“All assessments were up-to-date and reflected risks to people's nutrition and skin integrity, as well as risks to be considered if they needed to be evacuated from the building in an emergency.” from the report
Infection control
Inspectors were assured about infection prevention, use of protective equipment, testing, visiting arrangements and managing possible outbreaks.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Staff commitment
Inspectors found that staff were committed to providing good care, and people appeared comfortable when interacting with them.
“People appeared relaxed and comfortable when interacting with the staff team.” from the report
Not enough staff
seriousStaffing levels did not always meet people's needs, particularly on one floor. Staff had to prioritise people, creating a risk that needs could be overlooked.
“There are simply not enough staff to help people” from the report
Safeguarding records
needs fixingSome safeguarding investigations were incomplete. Low-level concerns were not always recorded, and records did not consistently show actions taken or lessons learned.
“A record of ongoing safeguarding's from earlier in the year were not complete with no details of action taken or lessons learned.” from the report
Weak governance
seriousQuality audits were not consistently completed, and an improvement plan did not show whether actions had been completed. There were no provider-level quality audits seen by inspectors.
“A recent improvement plan had actions identified but no indication they had been actioned.” from the report
Management instability
needs fixingThe home did not have a registered manager and staff said management had changed frequently. Staff had also received limited meetings, supervision and clinical guidance.
“The service did not have a registered manager, and this had been the case since 2019.” from the report
- 01How many staff are scheduled on each floor, especially the lower floor, and what happens when agency staff cannot fill a shift?
- 02What actions have been completed to improve staffing levels since this inspection?
- 03How are safeguarding concerns, including low-level concerns, recorded and reviewed?
- 04What quality audits are now completed, and how do you check that improvement actions have been finished?
- 05Who is the registered manager now, and how often do staff receive supervision and clinical guidance?
This was a focused inspection of Safe and Well-led, prompted by concerns about staffing and risk assessments; Effective, Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 24 September 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 Church House Care Home
9 rated inspections over 8 years: the service has improved, from Requires improvement to Good.
- August 2023Goodcurrent ratingup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- April 2021Goodstayed GoodSafe: GoodWell-led: Requires improvement
- October 2020Goodup from Requires improvementSafe: Requires improvementWell-led: Good
- May 2019Requires improvementup from InadequateSafe: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- October 2018Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- September 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- May 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- April 2014
Report published without a new overall rating.
- March 2014
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- November 2011
Registered with the Care Quality Commission on 1 November 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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