CQC report explained · a nursing home
What the CQC found at Churchview Nursing and Residential Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, March 2023
Churchview Nursing and Residential Home was rated Requires Improvement; inspectors found immediate safety issues, unlawful consent practices and weak checks on quality.
This was an unannounced focused inspection on 25 November and 5 December 2022. Inspectors checked Safe and Well-led, and also looked at Effective after finding concerns about consent and restrictions. They spoke with 12 people, 10 relatives and 8 staff, and reviewed care, medicines and management records.
The home was not always safe on the first day. Inspectors found unlocked or unlockable doors, damaged furniture, unclean areas and problems with infection control and fire safety records. The provider acted quickly, and the home was much cleaner and safer on the second day. Staff, staffing levels, recruitment, safeguarding and medicines were found to be safe.
People were restricted without clear capacity assessments or best-interest decisions. Some care records contained conflicting information. Quality checks had failed to identify problems with infection control, risks, care plans, consent and fire safety. The overall rating remained Requires Improvement, as it had at the previous inspection published in 2019.
Enough staff
Inspectors found enough staff to meet people's needs. Call bells were answered quickly and staff were visible on both floors.
“There were enough staff on duty to safely meet people's needs.” from the report
Medicines
Medicines were administered and stored safely. Staff understood the importance of medicines that must be given at particular times.
“Staff had received up to date medicines training.” from the report
Supportive staff
People and relatives spoke positively about the staff and the atmosphere in the home.
“People and relatives spoke positively about the service.” from the report
Unsafe premises and infection control
seriousOn the first inspection day, doors were unsecured, some furniture had sharp or damaged edges, and parts of the home were dirty or difficult to clean. Fire safety records and practices also had identified shortfalls.
“The premises weren't always safe.” from the report
Consent and restrictions
seriousRestrictions, including lap belts, were used without clear evidence of capacity assessments or best-interest decisions. Some consent records were unclear or contradictory.
“Restrictions were being imposed on people without evidence of capacity assessments or best interest decisions.” from the report
Weak quality checks
seriousThe provider's monitoring systems failed to identify problems with infection control, risk management, care plans, consent and fire safety. This was a breach of Regulation 17.
“The systems in place for checking the quality and safety of the service were not always effective” from the report
Unclear care records
needs fixingSome care plans gave conflicting information about people's capacity or abilities. CQC recommended that all care plans be reviewed.
“Some care plans contained conflicting information such as people's capacity to make decisions or people's capabilities.” from the report
No registered manager
needs fixingThere was no registered manager in post during the inspection. The home was overseen by a manager from another home with support from the clinical lead.
“At the time of the inspection there wasn't a registered manager in post.” from the report
- 01How are capacity assessments and best-interest decisions now recorded before any restriction, such as a lap belt, is used?
- 02How have you reviewed care plans to remove conflicting information about a person's capacity and abilities?
- 03What changes have been made to doors, furniture, cleanliness and infection control since the inspection?
- 04How are fire safety actions being tracked and checked now?
- 05Who is currently responsible for managing the home, and what progress has been made in recruiting a registered manager?
This was a focused inspection of Safe and Well-led, with Effective added after concerns about consent were found; Caring and Responsive were not inspected and their previous ratings were used in the overall rating. This explanation was written from the published report of 2 March 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, December 2019
Rated Requires Improvement; inspectors found kind, responsive care, but staffing, care records and management systems were not consistently reliable.
This was an unannounced inspection on 20 November 2019. Inspectors spoke with people, relatives, staff and visiting professionals. They reviewed care records, medicines records, recruitment, training and management records.
People were generally treated with kindness and respect, and the home offered a strong programme of activities. However, people sometimes waited too long for help because staff were not always available quickly. Some care plans, risk records and end of life plans lacked enough detail or were not up to date.
The service had gone through major staff changes and had become unsettled. A new registered manager had been in post for a few months and had started improvements, but inspectors found that progress was not yet consistent. The overall rating was Requires Improvement. Safe, Effective and Well-led were also Requires Improvement, while Caring and Responsive were Good.
Kind and respectful care
People and relatives generally said staff were kind and respectful. Inspectors also observed caring, person-centred interactions.
“There were warm, person-centred interactions between people, staff, managers and the provider.” from the report
Activities and social contact
The activities programme helped people stay engaged and reduced isolation. Families were also involved in some trips and events.
“The activities offer was a real positive at the service and source of much praise.” from the report
Food and nutrition support
Staff supported people with food and drinks, offered choices and made referrals where needed. Some people regained weight after moving into the home.
“There were positive examples of people regaining weight after moving into the service and their malnutrition scores had improved.” from the report
Safeguarding and medicines
Safeguarding concerns had been investigated and reported appropriately. Inspectors found that medicines were generally managed safely and audits had identified some earlier record gaps.
“Overall, the service supported people safely with their medicines.” from the report
Staffing and waiting times
seriousPeople sometimes had to wait for help because call bells were not always answered quickly. Staff recruitment was ongoing and the provider was reviewing staffing arrangements.
“Throughout the day of our visit, call bells were ringing for long periods and not always responded to quickly.” from the report
Incomplete care records
needs fixingSome risk, health, wound care and person-centred records were unclear, generic or not up to date. This could make it harder for staff to follow people's individual needs consistently.
“We found a variety of record-keeping issues that needed to be improved to underpin a safe, quality and person-centred service.” from the report
End of life planning
needs fixingThe home did not have detailed end of life care plans. Information about people's wishes was basic, although extra staff training had been arranged.
“There were currently no detailed end of life care plans in place.” from the report
Training completion
needs fixingSome mandatory training was incomplete, and introductory training for new staff needed to be strengthened. Inspectors received mixed feedback about the confidence of newer staff.
“Records showed there were some smaller gaps in mandatory training for all staff.” from the report
Communication and oversight
needs fixingCommunication with people, relatives and staff needed to improve after the period of major change. Audits also had gaps and did not always identify or resolve recurring problems effectively.
“We found effectiveness of audits at times needed to be improved, for example when recurring issues had been noted.” from the report
- 01What has changed since the inspection to make sure call bells are answered promptly and there are enough staff at busy times?
- 02Have all care plans and risk assessments been reviewed and made personal, current and detailed?
- 03What detailed end of life care planning is now in place for each person?
- 04How do you check that new staff have completed their introductory training and are competent before working independently?
- 05How often do you now meet with residents, relatives and staff, and how are concerns and feedback acted on?
This was an unannounced inspection covering all five CQC questions, and the report says the ratings had deteriorated from the previous inspection except Responsive, which remained Good. This explanation was written from the published report of 11 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 Churchview Nursing and Residential Home
4 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- March 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Churchview Nursing and Residential Home →
- December 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
Read what inspectors found at Churchview Nursing and Residential Home →
- June 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: OutstandingResponsive: GoodWell-led: Good
- March 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 24 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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