Churchview Nursing and Residential Home

Updated 2 March 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection team was made up of 2 inspectors and 2 Experts by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Churchview Nursing and Residential Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Churchview Nursing and Residential Home is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was not a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We reviewed feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.

During the inspection

We spoke with 12 people and 10 relatives about their experience of the care provided. We spoke with 8 members of staff including the interim manager, the clinical lead, a cook, a senior care worker, 2 care workers, the activities co-ordinator and a laundry assistant.

We reviewed documentation, inspected the safety of the premises and carried out observations in communal areas. We reviewed a range of records including 4 people’s care records, medicines records and quality audits. A variety of records relating to the management of the service, including policies and procedures were also reviewed.

Updated 2 March 2023

About the service

Churchview nursing and residential home provides personal and nursing care for up to 47 people, some of whom are living with dementia. At the time of the inspection there were 35 people living in the home.

People’s experience of using this service and what we found

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. We considered this guidance as there were people using the service who have a learning disability and or who are autistic.

The premises were not always safe. On the first day of inspection we found unlocked/unlockable doors, furniture in disrepair and areas of the home to be unclean or unfit for effective cleaning. The provider took immediate action to address the concerns which were significantly noticeable on the second day of inspection, which mitigated any risk and kept people safe. Improvements were being made to fire safety systems following an inspection from the Fire Service. Records about people’s care were not always clear, with some containing conflicting information. We have made a recommendation about this.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

The systems in place for checking on the quality and safety of the service were not always effective as they failed to identify shortfalls around infection control, the management of risk, care plans, consent and fire safety found during this inspection.

People were safeguarded from abuse. Risks to people’s health, safety and wellbeing were assessed and managed. There were enough staff to meet people’s needs and safe recruitment practices were followed. The provider learned from accidents and incidents to mitigate future risks. Medicines were safely administered and managed.

People’s needs were assessed before they moved into the home. Staff were suitably trained and received regular supervisions. People were supported with their nutritional needs and to access a range of health care professionals.

The home did not have a registered manager at the time of inspection. The provider was in the process of recruiting a new manager. The home was being overseen by a manager from another of the provider’s homes with the support of the clinical lead. The atmosphere in the home was calm and relaxed. Relative’s told us, “I just think it terms of the staff, they make the place great, the staff are really lovely. it’s really nice to see [family member] interact positively with them” and, “The general atmosphere is good and they (staff) are encouraging towards my [family member]. A system was in place to involve people, relatives and staff in the running of the home.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk.

Rating at last inspection

The last rating for this service was requires improvement (published 11 December 2019).

Why we inspected

The inspection was prompted in part due to concerns received in relation to staffing, fire safety, the culture and the overall management of the home. As a result, we decided to undertake a focused inspection to review the key questions of safe and well-led only.

During the inspection we found areas of potential concern relating to consent and restrictive practices. We therefore decided to also inspect the key question effective.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has remained requires improvement based on the findings of this inspection. We have found evidence that the provider needs to make improvements. Please see the safe, effective and well led sections of this full report.

We have approached the provider and requested immediate assurances around their improvement plan. As a result of this an action plan has been produced detailing how they would address the shortfalls identified and work to complete this had begun.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Churchview Nursing and Residential Home on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to consent and good governance at this inspection.

We have made a recommendation about care plans.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.