CQC report explained · a residential care home
What the CQC found at Church Road
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found safeguarding systems, risk assessments, safe recruitment and enough staff. Medicines management had improved, although a medicines safe key was briefly left on top of the safe and was moved back immediately.
- Effective?
- Good
- Care plans reflected people's needs and preferences. Staff received training and supervision, people were supported with healthcare appointments, and mental capacity and best-interest processes were in place.
- Caring?
- Good
- Staff were observed to be warm, friendly and kind. People were supported with privacy, dignity, relationships, choice and independence.
- Responsive?
- Requires improvement
- Care was personalised, but activity plans were not always followed. Relatives also gave mixed feedback about whether complaints and concerns received a timely response.
- Well-led?
- Good
- Managers had audits and action plans to monitor quality. Staff said the culture had improved, although relatives gave mixed feedback about communication and management changes.
What inspectors found, March 2020
Church Road rated Good overall; inspectors found safe, kind and well-led care, but activities and complaint responses were not always reliable.
This was an unannounced inspection over two days. Inspectors spoke with people, relatives and staff, and reviewed care records, medicines, incidents, accidents and complaints. They also gathered feedback from relatives after the visit.
The home was rated Good overall. Safe, Effective, Caring and Well-led were rated Good. Inspectors found enough staff, safe recruitment, improved medicines systems, suitable care plans and kind support that promoted people's dignity, choice and independence.
Responsive was rated Requires Improvement. Activity plans were not always followed. One person who needed regular walks was often taken for a drive instead, and another had only been out on seven activities in January 2020. Relatives also gave mixed feedback about how concerns were handled.
The previous inspection had rated the home Requires Improvement and found breaches involving medicines, safeguarding, governance and notifications. The report says improvements had been made and the home was no longer in breach. A previous warning notice about safeguarding had also been met.
Improved medicines safety
The home had introduced new checks, audits, training and competency checks. Inspectors found that people whose records were reviewed received their medicines as prescribed.
“People whose records we reviewed received their medicines as prescribed for them.” from the report
Personalised support
Care plans were detailed and reflected people's needs, preferences, communication and emotional support. Staff knew people well.
“Care plans were person-centred and detailed.” from the report
Kind and respectful staff
Inspectors observed warm and friendly support. People were helped to make choices, maintain relationships and do as much as possible for themselves.
“We observed staff were warm, friendly and kind to people.” from the report
Healthcare support
People were supported to attend appointments and had updated health action plans. Staff worked with health professionals and followed advice.
“Records showed people accessed the opticians, dentist, GP, and hospital appointments when required.” from the report
Improved management
The report says governance, safeguarding and medicines systems had improved since the previous inspection. Managers used audits and action plans to identify shortfalls.
“There were systems in place to monitor the standard of care provided at the service.” from the report
Activities were not always delivered
needs fixingPeople had activity plans, but daily records showed these were not always followed. This included missed regular walks and limited activities for one person.
“People's daily records showed that these plans were not always followed.” from the report
Mixed complaint responses
needs fixingRelatives could raise concerns, but feedback was mixed about whether they received a response. One relative had asked for the complaints procedure but had not received it.
“We received mixed feedback on whether they felt they would receive a response.” from the report
Communication with relatives
minorSome relatives said communication was not always good, and one said emails were answered only sometimes. Management changes were also described as unsettling by one relative.
“I have emailed them and sometimes I get answers sometimes I don't.” from the report
Temporary medicines storage
minorA key to one medicines safe had been left on top of it. Staff moved it back into a secure area during the inspection.
“At our inspection the key to one of the safes had been left out on top of it.” from the report
- 01How do you check that each person's activity plan is followed every day, including regular walks and community activities?
- 02What activities has my relative taken part in recently, and how do you record whether they happened?
- 03Can I have a copy of the complaints procedure, and what timescale do you use for responding to concerns?
- 04How will you keep me updated if my relative's needs, activities or care arrangements change?
- 05What checks are now in place to make sure medicines are stored securely and given as prescribed?
This was an unannounced planned inspection covering all five key questions and both the premises and care provided; the previous rating was Requires Improvement. This explanation was written from the published report of 27 March 2020 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, December 2019
Inspected but not rated; inspectors found safeguarding systems had improved and the warning notice requirements had been met.
This was an unannounced, targeted inspection on 21 November 2019. Inspectors checked whether the home had improved its safeguarding arrangements after a previous warning notice.
Inspectors found better systems for reporting possible abuse. Staff understood how to raise concerns inside and outside the home. Safeguarding incidents had been reported to the right people and authorities.
The warning notice requirements had been met. However, this was not a full inspection, so the home was not given new ratings. Its previous overall rating was Requires Improvement.
Improved safeguarding systems
The home had improved its systems for protecting people from abuse and avoidable harm.
“The systems in place to safeguard people had improved.” from the report
Staff understood reporting duties
Staff knew how to recognise abuse and how to report concerns both within the home and to outside authorities.
“Staff knew how to identify abuse and were aware of how to report it internally and externally.” from the report
Incidents were acted on
Inspectors found that safeguarding incidents had been acted on and reported to the appropriate people and authorities.
“Where there had been safeguarding incidents, appropriate action was taken to safeguard people, this including ensuring the appropriate people and authorities were made aware.” from the report
Limited inspection
minorThis inspection did not assess the whole Safe question or the other four questions. The home therefore did not receive new ratings.
“We will assess all of the key question at the next comprehensive inspection of the service.” from the report
Manager not yet registered
minorAt the time of the inspection, the home did not have its own manager registered with the CQC. A manager from another home was covering it.
“The service did not have a manager who was registered with the Care Quality Commission.” from the report
- 01What safeguarding improvements have been kept in place since this inspection?
- 02How are safeguarding and whistleblowing concerns recorded and reported now?
- 03Has the home appointed and registered its own manager with the CQC?
- 04What was the outcome of the previous safeguarding incidents mentioned in the report?
- 05When is the next comprehensive inspection expected?
This was a targeted inspection of specific safeguarding concerns under the Safe question; it did not assess the full Safe question or the other four questions, and it did not change the previous ratings. This explanation was written from the published report of 21 December 2019 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 Road
4 rated inspections over 4 years: the service has held its Good rating throughout.
- March 2020Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- December 2019Inspected but not ratedSafe: Inspected but not rated
- September 2019Requires improvementdown from GoodSafe: Requires improvementCaring: Requires improvementWell-led: Requires improvement
- June 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2014
Report published without a new overall rating.
- June 2014
Registered with the Care Quality Commission on 20 June 2014.
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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