CQC report explained · a nursing home
What the CQC found at Church Walk
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks, medicines, staffing and safeguarding were generally managed safely. They also found that some care records and risk assessments did not fully reflect people's complex needs, and the provider agreed to address this.
- Effective?
- Good
- This area was not inspected during this focused visit. Its previous rating was used in calculating the overall rating.
- Caring?
- Good
- This area was not inspected during this focused visit. Its previous rating was used in calculating the overall rating.
- Responsive?
- Good
- This area was not inspected during this focused visit. Its previous rating was used in calculating the overall rating.
- Well-led?
- Good
- Inspectors found an open and more positive culture, approachable management and quality monitoring systems. Some staff said they did not always receive regular supervision, and inspectors asked the home to improve feedback arrangements for people with communication difficulties.
What inspectors found, December 2020
Rated Good; inspectors found safe medicines and a more open culture, but care plans did not always reflect complex needs.
This was an unannounced focused inspection on 27 November 2020. Inspectors visited both units, spoke with a person using the service, relatives and staff, and checked care records, medicines records, staff files and management records.
The home was rated Good overall. Safe and well-led were both rated Good. Inspectors found medicines were managed safely, staff were recruited safely, the home was clean, and infection control arrangements were in place.
There were some areas needing improvement. Care plans did not always explain how health conditions affected behaviour or fully reflect complex needs. It was also difficult for some people to raise concerns because the complaints process was not easy to use.
This was a focused inspection of Safe and Well-led only. The other three areas were not inspected, so their previous ratings were used when calculating the overall rating. The overall rating remained Good.
Medicines managed safely
Inspectors found medicines were stored securely and that ordering, administration and monitoring systems were effective.
“Medicines were kept securely and there were effective systems for ordering, administering and monitoring medicines.” from the report
Clean and prepared for infection control
The home was clean and hygienic. Inspectors were assured that infection prevention measures and protective equipment were being used appropriately.
“The home was clean and hygienic and we were assured that the service was following infection prevention and control procedures.” from the report
Positive management culture
Relatives and staff described a more open and positive atmosphere under the new manager. The manager was seen as approachable.
“People told us the manager was approachable and they had worked hard to ensure a more open culture at the service.” from the report
Good communication with relatives
Relatives said they were kept informed about changes and regularly updated about their family members during the pandemic.
“They confirmed that regular contact was maintained and they were kept informed and updated of any changes happening within the home.” from the report
Care plans did not fully reflect complex needs
needs fixingSome care plans and risk assessments did not fully explain how people's health conditions affected their behaviour. Inspectors said proactive planning and analysis were sometimes lacking.
“Care plans on how best to support people did not always consider how people's health needs may be impacting upon their behaviour.” from the report
- 01How have you updated care plans to show how each person's health conditions may affect their behaviour?
- 02How do you identify and respond to patterns in behavioural incidents?
- 03What easy-read complaints and safeguarding information is now available for people with communication difficulties?
- 04How often do staff receive supervision, and how do you check that this is happening regularly?
- 05How can people with communication difficulties give feedback about the home?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not inspected and their previous ratings carried over. This explanation was written from the published report of 30 December 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
Rated Good; inspectors found safe care overall, but medicines records and staff competency checks were not always complete.
This was an unannounced inspection on 7 November 2019. It was prompted by concerns about medicines and poor management. Inspectors visited both units, spoke with people, a relative and staff, and reviewed care, medicines, recruitment and management records.
The home was rated Good for Safe and Well-led. Inspectors found enough staff, safe recruitment, risk assessments and suitable safeguarding procedures. Medicines were mostly managed safely, but there was one administration error, gaps in records for creams and similar treatments, and missing annual competency records for some staff.
The home had an interim manager because the previous registered manager was leaving. Inspectors found quality monitoring systems, clear responsibilities and a supportive approach. They found no evidence that the concerns which prompted the inspection had put people at risk of harm.
The report says the overall rating was Good, as was the previous rating published on 3 October 2019. CQC said it would continue monitoring information about the home and could inspect sooner if concerning information was received.
Enough staff
Inspectors found enough staff to meet people's needs. Staff said staffing levels allowed time for one-to-one support and activities.
“[There is] a good staff to person ratio. It allows us to take people out or spend time on a one to one with the people we support.” from the report
Safeguarding
Staff understood how to recognise and report abuse. Reported safeguarding concerns were investigated and passed to the relevant authorities.
“Where safeguarding concerns were reported these were appropriately investigated and reported to the relevant authorities.” from the report
Risk management
Care records included risk assessments and instructions for staff. Environmental checks and certificates were used to help keep the premises safe.
“Care records included risk assessments. Where risk was identified care plans provided instruction to staff on how to manage risks.” from the report
Quality monitoring
Inspectors found systems for checking safety and quality. The home had clear lines of responsibility and took action when shortfalls were identified.
“There were effective systems in place to monitor and improve the quality of the service.” from the report
Supportive leadership
Staff told inspectors that the interim manager was approachable and supportive. Inspectors also found positive working relationships with families and partner organisations.
“Staff told us that the new manager was approachable and that they had already found them to be supportive and helpful.” from the report
Topical medicines records
seriousSome records for creams, ointments and medicated shampoos were incomplete. Inspectors could not be sure these medicines had always been given as prescribed.
“There were some gaps in records for topical preparations. This meant that we could not be sure that any prescribed creams, ointments or medicated shampoos had been administered as prescribed.” from the report
Medicine administration error
seriousInspectors found one medicine administration error. The clinical manager said it would be investigated.
“However, we found one administration error which the clinical manager assured us would be investigated.” from the report
Medicine competency checks
needs fixingSome staff who administered medicines did not have annual competency records in their files. The manager said the required assessments would be completed.
“However some staff did not have annual competency records in their file to meet national guidance.” from the report
Management changes
needs fixingThe home had an interim manager, and one staff member said it had been their seventh manager in four years. Inspectors also found that some staff were not aware the previous manager was leaving.
“One health care assistant told us that this was their seventh manager in the past four years.” from the report
- 01Have all records for creams, ointments and medicated shampoos been completed consistently since this inspection?
- 02What was the outcome of the medicine administration error investigation?
- 03Do all staff who administer medicines now have up-to-date competency assessments?
- 04Who is the registered or interim manager now, and how are staff informed about management changes?
- 05What are the current CQC ratings for Effective, Caring and Responsive, which were not assessed in this inspection?
This was a focused inspection prompted by concerns about medicines and management, and it rated Safe and Well-led only; the other three key questions were not rated in this report. 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 Walk
5 rated inspections over 6 years: the service has held its Good rating throughout.
- December 2020Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2019Goodstayed GoodSafe: GoodWell-led: Good
- October 2019Goodstayed GoodSafe: GoodWell-led: Good
- February 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2015GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- January 2014
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- June 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 17 November 2010.
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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