CQC report explained · a nursing home
What the CQC found at Church Terrace Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from avoidable harm. Risks were reviewed, medicines were managed safely, staff were recruited safely, and inspectors found enough staff to support people.
- Effective?
- Good
- People's care plans and assessments were reviewed. Staff supported people with consent, nutrition and healthcare, and worked with other agencies.
- Caring?
- Good
- This question was not assessed during this focused inspection. Its rating was carried over from the previous inspection.
- Responsive?
- Good
- This question was not assessed during this focused inspection. Its rating was carried over from the previous inspection.
- Well-led?
- Requires improvement
- The culture was positive, but quality monitoring was not always reliable. Mattress settings and records about action taken after high blood sugar readings needed clearer checking and recording.
What inspectors found, December 2023
Church Terrace Nursing Home is rated Good; inspectors found safe, effective care but quality checks and records still needed improvement.
This was an unannounced, focused inspection on 26 October 2023. Inspectors spoke with 8 people, 8 relatives, 13 staff and one visiting professional. They reviewed care and medicines records, staff recruitment files, and records about how the home was managed.
The home had improved since the previous inspection. Inspectors rated Safe and Effective as Good. They found enough staff, safe medicines management, suitable risk assessments, trained staff, good support with food and healthcare, and better arrangements for consent.
Well-led remained Requires Improvement. Checks on some mattresses and records about high blood sugar levels were not clear enough. New quality monitoring systems had been introduced, but inspectors said they needed time to show they worked consistently. The overall rating changed from Requires Improvement to Good.
Safe medicines
Medicines were given at the right time by trained staff and stored safely. Records matched the quantities of medicines held.
“Medicines were managed safely by trained staff. People received their medicines at the right time and medicines were stored safely.” from the report
Enough staff
Inspectors found enough staff to support people safely, including people who needed one-to-one support. People said they did not have to wait long for help.
“There were enough staff on duty to support people safely, this included people who required 1:1 level of support.” from the report
Support from other services
The home worked with health and social care professionals. Inspectors found that referrals were made and people's health concerns were escalated promptly.
“Staff worked in partnership with several different agencies to provide safe and effective care.” from the report
Positive culture
People, relatives and staff described the atmosphere and management as positive. Relatives said they were kept informed and involved.
“Relatives told us the culture was positive and welcoming.” from the report
Mattress checks
needs fixingMonitoring of airflow mattress settings was not clear enough. The home introduced a new system after inspectors raised this issue.
“The monitoring of this setting needed clearer recording and quality checking.” from the report
Diabetes records
needs fixingWhen one person's blood sugar was high, the records did not explain what action staff had taken. The manager improved the recording system after inspectors gave feedback.
“However, action taken in response to high blood sugar levels was not always clear.” from the report
New monitoring systems
minorThe manager had introduced several new quality checks, but they had not been in place long enough to show whether they would work consistently over time.
“These new systems needed time to be embedded to monitor their success and sustainability.” from the report
Tired furnishings
minorSome chairs and furnishings needed replacing, and some communal areas looked tired. The provider had begun redecorating and showed plans to replace furniture.
“Some chairs and furnishing needed replacing.” from the report
- 01How do you now check that each person's airflow mattress is set correctly, and how is this recorded?
- 02What action do staff take when a person's blood sugar is high, and how do you check that the action is recorded?
- 03What evidence can you show that the new quality monitoring systems are working consistently?
- 04What furniture and communal areas have been replaced or renovated since the inspection?
- 05What were the current ratings for Caring and Responsive at the previous inspection?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and their ratings carried over from the previous inspection. This explanation was written from the published report of 6 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, June 2023
Church Terrace Nursing Home was rated Requires Improvement; inspectors found caring staff but serious gaps in risk assessments, medicines, consent and oversight.
This was an unannounced focused inspection on 21 and 30 March 2023. Inspectors looked at Safe, Effective and Well-led after concerns about staff conduct and possible risks. They spoke with people, relatives and staff, reviewed care and medicine records, and checked policies, recruitment files and building safety documents.
People generally said they felt safe. Inspectors found enough safely recruited staff, caring support, training, food choices, access to health professionals and support for visitors. However, care plans and risk assessments were not always detailed, medicines were not always managed safely, and some building safety and infection-control actions were unfinished.
The home was not always following the law about consent and best-interest decisions. Its quality checks had not made sure improvements were completed. The overall rating remained Requires Improvement. Safe and Well-led also remained Requires Improvement, while Effective fell from Good to Requires Improvement.
People felt safe
People and relatives generally said they felt safe and had no concerns about the way staff treated them.
“People told us they felt safe in the home. People and relatives were complimentary of the care.” from the report
Enough staff
Inspectors found enough staff to support people, and recruitment checks were carried out.
“There were enough safely recruited staff to support people.” from the report
Training and support
Staff received regular training and support, including agency staff working in the home.
“Staff were trained and supported to be effective in their role.” from the report
Food and choice
People could choose meals and alternatives, and modified diets were provided where needed.
“We observed people had choices at lunch time and could have alternative options if they did not want the main choices.” from the report
Open communication
Relatives described managers and staff as approachable, and said they were updated about problems and incidents.
“They listened to what we said, contacted us by email and updated us on what they'd done.” from the report
Incomplete risk information
seriousSome care plans and risk assessments did not explain clearly how staff should keep people safe. Inspectors said this increased the risk of harm.
“The lack of detailed care plans and risk assessments and medicines information placed people at increased risk of harm.” from the report
Medicines not always safe
seriousSome medicine stock levels did not match the records, so inspectors could not be sure people always received medicines as prescribed. Instructions for some medicines given when needed were also incomplete.
“Not all medicine stock levels matched, we found some discrepancies so we could not be sure people always received their medicines as prescribed.” from the report
Consent decisions
seriousMental capacity assessments and records about restrictions were not always clear. Inspectors could not be sure some covert medicines decisions had always been made in people's best interests.
“People were not supported to consent in line with their individual needs.” from the report
Weak quality checks
seriousThe home's monitoring systems did not reliably make sure actions were completed. Some fire actions were marked complete even though inspectors found they were not finished.
“Quality assurance systems in place had not always ensured actions were completed and improvements swiftly completed.” from the report
Cleaning and food labelling
minorThe home was generally clean and odour free, but some areas needed a deep clean. Some food was not labelled with its opening date or had expired.
“There were some instances of food not being labelled as to when it was opened, or it had expired and had not been disposed of.” from the report
- 01Which care plans and risk assessments were incomplete at the inspection, and have they all now been updated?
- 02How do you check that medicine stock matches records and that people receive medicines as prescribed?
- 03How are mental capacity assessments, best-interest decisions and restrictions now recorded and reviewed?
- 04Which fire safety and infection-control actions were outstanding, and when were they completed?
- 05How will you show families that the improvement plan is complete and that the changes have been maintained?
This was a focused inspection of Safe, Effective and Well-led only; no separate ratings were given for Caring or Responsive in this report, and the circumstances of a person's death were not examined. This explanation was written from the published report of 3 June 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.
Every inspection of Church Terrace Nursing Home
5 rated inspections over 7 years: the service has held its Good rating throughout.
- December 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2023Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- November 2022Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodWell-led: Requires improvement
- October 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- April 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 17 January 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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