CQC report explained · a nursing home
What the CQC found at Churchfields Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found more detailed risk assessments, safe medicines management, enough staff, suitable recruitment checks and infection control systems. Staff did not always record the reasons for giving medicines prescribed to be taken when required.
- Effective?
- Good
- This key question was not covered by this focused inspection. The report says the previous rating was used to calculate the overall rating.
- Caring?
- Good
- This key question was not covered by this focused inspection. The report says the previous rating was used to calculate the overall rating.
- Responsive?
- Requires improvement
- The range of activities and stimulation could be improved, and some people had little to do during the day. Some care monitoring records had gaps, and one person's communication plan did not clearly explain how staff should be supported to communicate with them.
- Well-led?
- Good
- The provider had improved its digital care planning and quality audit systems. The management team reviewed incidents, acted on feedback and showed that previous weaknesses in governance had been addressed.
What inspectors found, April 2023
Rated Good overall; inspectors found safe and well-led care, but the home was not always responsive to people's activity and recording needs.
This was an unannounced focused inspection on 21 March 2023. One inspector, a nursing specialist and an Expert by Experience visited the home. They spoke with people, relatives and staff, watched care, and checked care plans, medicines and other records.
The home was rated Good overall. Safe and Well-led were rated Good. Inspectors found better risk assessments, safe medicines management, enough staff, suitable recruitment checks and improved quality monitoring.
Responsive remained Requires Improvement. Some people had little to do during the day. Inspectors also found gaps in some monitoring records and one communication plan that did not clearly explain how staff should communicate with the person.
The previous overall rating was Requires Improvement, with breaches relating to safe care and treatment and good governance. The provider had made enough improvement in those areas and was no longer in breach. This inspection did not cover Effective or Caring, so those ratings were carried forward from the previous inspection.
Better risk management
Risk assessments were more detailed and gave staff clearer instructions about health, mobility, nutrition, skin and medicines risks.
“At this inspection, we found risks assessments relating to people's health and care needs were more robust.” from the report
Safe medicines
Medicines were stored, administered and audited safely. Staff received relevant training and regular competency checks.
“Medicines were managed safely in line with national guidance. Medicines were administered by staff who had received the relevant training and who underwent annual assessments of their competency.” from the report
Enough suitable staff
Inspectors found staffing levels met the home's assessed needs. Recruitment checks included criminal background checks, references and eligibility to work in the UK.
“There were enough staff to support people in the home.” from the report
Improved leadership
The management team had stronger audits and a better digital care planning system. It used incidents and feedback to identify improvements.
“The provider had implemented a more effective digital care planning system and we saw that it contained detailed assessments of people's needs and person-centred care plans.” from the report
Family contact
People were supported to see family and friends, and relatives were involved in discussions about care and concerns.
“People were being supported to develop and maintain relationships with their family and friends.” from the report
Gaps in care records
needs fixingSome turning charts for people at risk of pressure sores had unexplained gaps. Staff could not clearly explain one person's leg-turning needs, and the care plan did not set this out clearly.
“We noted some care monitoring records, such as turning charts for people at risk of pressure sores contained some gaps.” from the report
Reasons for some medicines not recorded
needs fixingStaff did not always record why medicines prescribed to be taken when required had been given. The manager said this would be addressed with staff.
“However, staff did not always document the reasons for administering them.” from the report
One communication plan unclear
needs fixingOne person could not communicate verbally, but their plan did not clearly say what measures staff should use to communicate with them.
“However, we did note that one person was not able to express themselves verbally and their communication plan did not clearly set out what measures staff use to communicate with them.” from the report
- 01What activities are planned each week for my relative, and how will you make sure they have meaningful things to do each day?
- 02How do you check that turning charts and other care monitoring records are completed without gaps?
- 03How are medicines given when required recorded, including the reason they were needed?
- 04How is my relative's communication method recorded and explained to every member of staff?
- 05What checks now show that the previous problems with risk assessments and quality monitoring have stayed improved?
This was a focused inspection of Safe, Responsive and Well-led; Effective and Caring were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 29 April 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, January 2022
Churchfields Nursing Home was rated Requires Improvement; inspectors found kind care and safe medicines, but gaps in risk assessments, care planning and oversight.
This was an unannounced inspection on 30 November 2021. Inspectors spoke with people, relatives, staff and managers. They reviewed five care plans, four staff files, medicines records and quality checks.
The home was rated Good for effective and caring care. People were treated kindly, supported to make choices and helped to access healthcare, meals and activities. Medicines, staffing, recruitment and infection control were managed safely.
The overall rating was Requires Improvement. Risk assessments did not always cover important health conditions, and care plans for people with dementia were not person-centred enough. Quality checks had not found these problems, and some complaints were not handled promptly or courteously.
The previous overall rating was Good, published in August 2019. Responsive and well-led care fell from Good to Requires Improvement. The home was asked for an action plan, and CQC said it would monitor progress and return for another inspection.
Kind and respectful care
People were treated with kindness and respect. Staff supported privacy and encouraged people to remain independent.
“We observed relationships between staff and people were friendly and positive.” from the report
Safe medicines
Inspectors found that medicines were stored and administered safely, including medicines given when needed.
“We saw evidence that people received their medicines as prescribed, including those to be given when required (known as PRN medicines).” from the report
Staffing and safeguarding
There were suitable numbers of staff, recruitment checks had been completed, and staff understood how to protect people from abuse.
“There were appropriate numbers of staff to support people safely.” from the report
Activities and healthcare
People had access to regular group and one-to-one activities, as well as GPs, district nurses and other healthcare services.
“People were supported with regular activities to support people's interests that were relevant to them.” from the report
Incomplete risk assessments
seriousRisk assessments did not consistently explain the risks linked to conditions including diabetes, dehydration, breathing difficulties and blood-thinning medicines. Inspectors said this placed people at risk of harm.
“Risk assessments were either not in place or were not robust enough to demonstrate safety and risk was effectively managed.” from the report
Dementia care plans
needs fixingCare plans for people with dementia did not explain their level of dementia or how support should be personalised.
“Care plans had not been completed for people with dementia to include their level of dementia and how support can be personalised to ensure they received person-centred care.” from the report
Weak quality checks
seriousAudits had not identified the gaps in risk assessments, dementia care plans and oral healthcare plans. This was one of the legal breaches.
“There was not an effective quality assurance system in place to identify shortfalls and act on them to ensure people were safe.” from the report
Complaint responses
needs fixingSome complaints were not answered within the timescales in the home's policy. Inspectors also said the language used in some replies should have been more courteous.
“Some complaints had not been responded to in a timely manner in accordance to the providers complaints policy.” from the report
- 01Have you completed new risk assessments for diabetes, dehydration, breathing difficulties and blood-thinning medicines?
- 02How are dementia care plans now personalised, and can we see an example?
- 03What changes have been made to quality audits so they identify missing or incomplete records?
- 04How are oral healthcare needs recorded and reviewed?
- 05How do you make sure complaints are answered on time and in a courteous way?
This was an unannounced full inspection covering all five key questions, including infection prevention and control; the previous overall rating was Good, but Responsive and Well-led fell to Requires Improvement. This explanation was written from the published report of 13 January 2022 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 Churchfields Nursing Home
6 rated inspections over 8 years: the service has improved, from Inadequate to Good.
- April 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- January 2022Requires improvementSafe: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- February 2021Inspected but not ratedSafe: Inspected but not rated
- August 2019Goodstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2015Requires improvementup from InadequateSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2015InadequateSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- April 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- June 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 30 December 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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