CQC report explained · a residential care home
What the CQC found at The Churchley Rest Home Limited
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, December 2019
Rated Requires Improvement; inspectors found kind, personalised care but problems with consent, medicines checks and quality monitoring.
The inspection was unannounced and took place on 22 October 2019. Inspectors spoke with seven people, two relatives, staff and managers. They observed care and checked care, medicines, recruitment and management records.
People generally felt safe and well cared for. Inspectors found enough staff, safe recruitment, clean premises, kind staff, personalised care, activities and good support with food and healthcare.
There were important weaknesses. One person who had capacity to decide was not supported to leave the home when they wished to return home. Medicines checks did not find two medicines that should have been disposed of, and some audits had not identified these problems.
The overall rating fell from Good to Requires Improvement. Safe, Caring and Responsive were rated Good. Effective and Well-led were rated Requires Improvement.
Kind and respectful staff
People were treated with kindness, dignity and respect. Staff supported independence and knew people's preferences and needs.
“People were supported by staff who were patient, kind and friendly. Positive caring relationships had been developed.” from the report
People felt safe
Risks were identified and managed, staff understood safeguarding and there were enough staff to meet people's needs.
“People told us they felt safe living at the home.” from the report
Personalised care
Care plans included detailed information about people's preferences, communication needs and how they wished to be supported.
“Care plans were written in a person-centred way and contained detailed information about people, their preferences, and how they wished to be supported.” from the report
Activities and relationships
People had a range of activities and were supported to keep in touch with family, friends and community interests.
“People were happy with the activities planned for them.” from the report
Clean home
Inspectors found the home clean and fresh, with staff using protective equipment during personal care.
“The home was clean and smelled fresh.” from the report
Consent and choice
seriousOne person wanted to return to their own home and had capacity to make this decision, but staff did not act promptly. The person was prevented from living at home without lawful authority.
“The provider had not assessed the person's needs in a timely manner or assessed their capacity to make a decision in relation to them staying at the home.” from the report
Medicines checks
needs fixingTwo medicines in the refrigerator had not been disposed of when required. A medicines trolley was also left with tablets on top while it was unattended, although inspectors said this did not pose a risk at the time.
“There was no detailed medicines audit, although there was a book which recorded the disposal of medicines and medicines coming into the home.” from the report
Weak quality monitoring
needs fixingThe home's audits did not identify the consent and medicines problems found during the inspection. This meant the management checks were not consistently effective.
“Audits had not been effective in identifying that these were areas in need of improvement.” from the report
Limited formal meetings
minorResidents' meetings were not regular and staff meetings took place annually. Inspectors noted that people and staff were also asked for views informally.
“Residents' meetings did not take place on a regular basis, but people were asked for their views about the home on a more informal basis.” from the report
- 01What action have you taken to make sure each person's capacity and consent to stay at the home are assessed promptly?
- 02How do you support a person who has capacity and wants to leave the home?
- 03What medicines audit is now in place, and how do you check that expired or unwanted medicines are removed and disposed of?
- 04How do your quality checks identify problems that may not be found through routine audits?
- 05How often do you now hold residents' and staff meetings, and how are suggestions followed up?
This was an unannounced inspection covering all five CQC questions, including the premises and care provided; the previous Good rating had changed because of the findings at this inspection. 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.
What inspectors found, February 2017
Rated Good overall; inspectors found safe, kind and responsive care, but the home’s leadership and quality checks required improvement.
Inspectors visited unannounced on 11 January 2017. They spoke with people living in the home, visitors, care staff and the provider. They reviewed care records, medicines records, staff records, audits and incidents. They also observed care, lunch and medicines being given.
The home was rated Good for safe, effective, caring and responsive care. People were protected from harm, received their medicines safely, had suitable food and healthcare, and were treated with kindness and respect. Care plans reflected people's needs and preferences, and people could choose activities and how they spent their time.
The home was rated Requires Improvement for well-led. The provider had created quality checks after the previous inspection, but these had not yet been put into practice or embedded. The earlier breaches had been resolved, including concerns about medicines, nutrition monitoring, policies and notifications to CQC.
Safe medicines support
Medicines were stored, administered and disposed of safely. Staff were trained and their competence had been checked.
“People received their medicines on time and according to their preferences, from staff with the necessary training and who had their competence assessed.” from the report
Kind and respectful care
Inspectors saw warm relationships between staff and people. Staff respected privacy, dignity, choices and independence.
“People were treated with kindness and compassion. Staff were caring and respectful in their approach” from the report
Individual care planning
Care plans included people's social, emotional, physical and health needs, along with their interests and preferences. People and relatives were involved in planning and reviews.
“Care plans contained information about peoples' interests, hobbies and employment history and provided staff with an insight into peoples' lives” from the report
Food and drink
People said they were happy with the quality, quantity and choice of food and drink. Staff respected people's preferred place to eat and offered alternatives.
“People told us they were happy with the quality, quantity and choice of food available.” from the report
Quality checks not embedded
needs fixingThe provider had obtained external help to create quality assurance audits, but these had not yet been put into practice. This meant the home needed stronger oversight of whether care systems were effective.
“Quality assurance processes to ensure the delivery of high quality care and drive improvement had been devised but were yet to be implemented or embedded in practice.” from the report
- 01Have the quality assurance audits now been implemented, and how often are they completed?
- 02What changes were made after the previous concerns about medicines, and how do you check that medicines records remain accurate?
- 03How do you monitor people's food, drink and weight if they are at risk of malnutrition?
- 04How are people's care plans reviewed when their needs, preferences or health change?
This was an unannounced comprehensive inspection covering all five CQC questions, including care records, medicines, staffing, incidents, quality audits and observations of care. This explanation was written from the published report of 22 February 2017 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 The Churchley Rest Home Limited
3 rated inspections over 4 years: the service has held its Requires improvement rating throughout.
- December 2019Requires improvementcurrent ratingdown from GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at The Churchley Rest Home Limited →
- February 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at The Churchley Rest Home Limited →
- January 2016Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 25 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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