Church House Care Home

Updated 4 August 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 was carried out by 2 inspectors, a specialist nurse advisor and an Expert 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

Church House Care 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. Church House 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. A new manager had recently been appointed and had applied to register. We are currently assessing this application.

Notice of inspection

This inspection was unannounced.

What we did before inspection

We reviewed information we had received about the service since the last inspection and sought feedback from the local authority. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 10 people who used the service and a visiting relative about their experience of the care provided. We spoke with 12 members of staff including the manager, regional managers, nurses, team leaders, care staff and maintenance staff.

We reviewed a range of records. This included 12 people's care records and several medication records. We looked at 3 staff files in relation to recruitment and staff training. A variety of records relating to the management of the service, including policies and procedures were reviewed.

Updated 4 August 2023

About the service

Church House Care Home is a care home providing personal and nursing care to older people, some of whom were living with dementia. The home can accommodate up to 44 people. At the time of this inspection 26 people were using the service.

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

People and their relatives were positive about the care and support they received at Church House. They told us staff were caring and responsive.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. However, records relating to this in some cases needed a more prompt review if there had been changes.

We have made a recommendation for the provider to review the process for keeping MCA assessments and decisions under review, to ensure any changes are responded to promptly.

Overall, there were enough staff support people safely and the provider was keeping this under review. New staff had been recruited and the use of agency staff had reduced since the last inspection. The provider had paused new admissions until they were fully staffed. Staff had been recruited safely.

Risk assessments were undertaken, and staff took action to minimise risks. However, we saw an example where a person’s risk assessment was not reflective of their needs. Some care plans would benefit from further updates and person-centred detail. The provider had identified this, and action was being taken.

People told us they felt safe at Church House. Staff had been trained and understood their responsibility to report any safeguarding concerns. There was a welcoming and friendly atmosphere at the home. People’s medicines were managed safely.

The home was clean and well maintained. Fire safety measures were in place. Some checks were in progress following the appointment of a new maintenance operative. There was an up-to-date Infection prevention and control (IPC) policy in place and managers undertook regular IPC audits.

There was a new manager in post. People living at the home and staff were familiar with him and positive about the overall management. Despite management changes staff told us they were a good staff team and felt supported.

People and relatives were regularly asked for feedback. The culture of the home promoted positive outcomes for people and the new manager was further focusing on engagement with people.

Governance and oversight had improved. This included various audits and checks. A recent in-depth audit had been carried out and a detailed home improvement plan was being actioned.

Staff worked in partnership with various health professionals to improve people's care and outcomes.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 24 September 2021) and there were 2 breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations. However, ongoing improvements were required in some areas.

Why we inspected

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.

We carried out an unannounced comprehensive inspection of this service on 27 July 2021. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment and good governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

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 changed from requires improvement to good. This is based on the findings at this inspection.

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

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.