CQC report explained · a nursing home
What the CQC found at Church Rose Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- People's risks were assessed and medicines were managed safely. However, infection prevention practices and records were not consistently reliable, including cleaning records for equipment and staff clothing and jewellery.
- Effective?
- Requires improvement
- Staff were trained and people generally received suitable food, healthcare and support. The provider did not consistently record or act on conditions attached to three people's Deprivation of Liberty Safeguards authorisations.
- Caring?
- Good
- Inspectors saw kind interactions. People and relatives said staff were caring, respectful and supportive of independence, and people were involved in everyday choices and care reviews.
- Responsive?
- Good
- Care plans reflected people's needs and preferences, and people were offered choices. The home supported relationships, communication, activities and end-of-life wishes, although records did not always show social support for people who stayed in their rooms.
- Well-led?
- Requires improvement
- The manager and staff were described as approachable and willing to improve. However, governance systems and audits had not identified or dealt with some safety, DoLS and record-keeping problems quickly enough.
What inspectors found, December 2023
Church Rose Nursing Home was rated Requires Improvement overall; care was kind and responsive, but safety, consent and management systems needed improvement.
Inspectors visited on 1, 2 and 7 November 2023. The inspection was unannounced at first. They spoke with people, relatives, staff and health professionals, and reviewed care plans, risk assessments, medicine records, staff files and quality checks.
The home was rated Good for Caring and Responsive. People were treated kindly, involved in decisions and supported to maintain relationships. Staff knew people well, medicines were managed safely, and people could access healthcare and activities.
The home was rated Requires Improvement for Safe, Effective and Well-led. Inspectors found problems with infection control records and practice, recording and acting on Deprivation of Liberty Safeguards conditions, and the effectiveness of quality checks. The provider acted on some issues during and after the inspection, but CQC requested an action plan and will monitor progress.
Kind and respectful care
People and relatives described staff as kind and caring. Inspectors saw people relaxed around staff and able to make requests.
“People were well supported, and privacy, dignity and independence were respected and promoted.” from the report
Medicines managed safely
The medicine records checked were clear, including instructions for medicines taken when needed. Stock balances were correct for the medicines inspected.
“People were supported to receive their medicines safely.” from the report
Good links with healthcare
The home worked with health professionals and made referrals to services such as physiotherapy, dietetics and speech and language therapy.
“People were supported to access healthcare services and referrals to additional support services such as Occupation Therapy (OT), Speech and Language Therapy (SaLT), dietician and physiotherapist had been made.” from the report
Personalised support
Care plans and risk assessments generally reflected people's needs, wishes and interests. Staff knew people well and supported independence and family contact.
“People were supported as individuals, in line with their needs and preferences.” from the report
DoLS conditions were not consistently followed
seriousFor three people, conditions attached to authorised Deprivation of Liberty Safeguards were not recorded consistently or acted on in a timely way. This was a legal breach and could have meant people did not receive their legally assessed support.
“We found for 3 people who had authorised DoLS with identified conditions, the provider had failed to ensure they were recorded consistently and in a timely way to guide staff.” from the report
Infection control was inconsistent
needs fixingInspectors found gaps in equipment cleaning records and saw practices involving jewellery, acrylic nails, clothing, meal tables and storage of items that could increase infection risks. Management addressed several of these issues during the inspection.
“People were not always protected from the risk of infection as staff were not consistently following safe infection prevention and control practices.” from the report
Quality checks did not find problems quickly enough
seriousThe provider had audits and monitoring systems, but they had not identified or resolved some DoLS, infection control and record-keeping issues promptly. This was a breach of the good governance regulation.
“The provider's systems did not always effectively monitor the quality of care provided to drive improvements.” from the report
Some care records were incomplete
needs fixingDaily records did not always show support with activities or access to communal areas. Bath water temperature checks were also not consistently recorded, although staff said the support had taken place.
“Although staff knew people well and how to meet their needs, this was not always supported by the records.” from the report
- 01What action has been taken to make sure every current DoLS condition is recorded in the person's care plan and followed by staff?
- 02How do you now check and record that hoists and other equipment are cleaned after every use?
- 03What changes have been made to your audits so that infection control and care-record problems are found and fixed promptly?
- 04How do you record activities and social contact for people who choose or need to stay in their rooms?
- 05How will you show families that the improvements identified during this inspection have been maintained?
This was an unannounced inspection covering all five CQC questions, including both the premises and the care provided; inspectors visited on three days and reviewed records for 12 people. This explanation was written from the published report of 9 December 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, May 2018
Church Rose Nursing Home is Rated Good; inspectors found safe, kind and responsive care, with improvements since the previous inspection.
Inspectors visited without warning on 7 February 2018. They spoke with people living at the home, relatives, staff and healthcare professionals. They also observed care and checked care plans, medicines records, risk assessments, audits and other records.
All five areas were rated Good: safe, effective, caring, responsive and well-led. People said they felt safe, valued staff and received care that respected their needs, choices and cultural beliefs.
The home had improved from Requires Improvement at the previous inspection. Inspectors noted more stable staffing, less use of agency staff, stronger management and better systems for checking care and sharing learning.
Consistent staffing
Staffing was stable and the home had reduced its reliance on agency workers. Inspectors said this helped staff know people better and helped people feel more comfortable.
“They told us they had reduced their reliance on agency staff and this had helped staff get to know people and for people to feel more comfortable around staff.” from the report
Kind and respectful care
Inspectors saw staff showing kindness and understanding people's individual needs. People said staff were caring and respectful.
“Throughout the inspection we saw examples of staff demonstrating kindness to people they were supporting and staff had an instinctive understanding of their needs.” from the report
Care adapted to changing needs
Care plans were reviewed and amended when people's health or circumstances changed. Relatives were involved in discussions about care.
“We looked at four care plans and saw that people's care was reviewed and updated in response to any changing circumstances.” from the report
Improved management
A new manager had introduced more team-based working and stronger checks on care. Staff said communication and teamwork had improved.
“The registered manager had been at the home for a short period of time but had worked with staff to change practices within the home and promote a more team based way of working.” from the report
Activities and personal beliefs
People could take part in communal and individual activities, including a choir, gentle exercise and support for religious beliefs.
“People living at the home were involved in a choir. People were also offered gentle exercise and support with their religious beliefs.” from the report
Inspectors raised no specific concerns in this report.
- 01How are you using the electronic care planning system to spot and respond to changes in my relative's needs?
- 02What staffing levels are in place for each shift, and how often do you need agency staff now?
- 03How will you support my relative's cultural, religious and dietary preferences?
- 04What activities would be available for my relative, including individual interests as well as group activities?
- 05How would you involve our family in end of life planning and respond to any complaints or concerns?
This was an unannounced inspection of the overall service, covering all five CQC questions and including observations, discussions and checks of care and management records. This explanation was written from the published report of 16 May 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 Rose Nursing Home
5 rated inspections over 9 years: the service has held its Requires improvement rating throughout.
- December 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2018Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- January 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- March 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- July 2011
Registered with the Care Quality Commission on 19 July 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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