The Churchley Rest Home Limited

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 63 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. For example, on several occasions following a fall, the correct post fall procedures and moving and handling plans had not been followed, and relatives had not been notified accordingly. Lessons were not always learnt to continually identify and embed good practice. Whilst there were systems and processes in place to report and record incidents and accidents, further improvements were required to embed a learning culture. Feedback from relatives was mixed around the correct procedures being followed when an incident or accident had occurred. One relative told us, “[Name] had a series of falls. They go to her quickly. I found out about the falls from my [name] though, they didn’t let me know. This has happened a couple of times.” A new system, post fall analysis had been brought in, and further development was ongoing around staff roles and responsibilities and the correct procedures to follow.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. Pre assessments were carried prior to people moving into the service and people told us they were able to visit and look round the service and meet people before deciding if the service was suitable for them. People were supported to attend medical appointments. One person told us, “The registered manager is really good. When I need a lift the registered manager will take me, in the past I had foot trouble, and the registered manager stayed with me. They take us to any appointments.”

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately. Policies and procedures were in place for safeguarding, however these had not been followed by the management team and staff. For example A person had had a fall that required hospital intervention and staff had not followed the correct procedure following the fall. They had not raised safeguarding concerns promptly. A safeguarding should be raised in the event where an incident has occurred that may have resulted from abuse or neglect. The home should alert the local authority to ensure the person receives appropriate support such as input from the Falls Prevention Team or Occupational Therapy. Staff had the received safeguarding training and understood the different types of abuse people might face. One relative told us, “The staff are angels, but they lack training in some areas. They shouldn’t have lifted [name] up when they had their fall.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. The provider was in the process of transferring care plans and risk assessments on to a new electronic system, but the transfer had not yet been completed. This was an ongoing process to ensure that people had up to date risk assessments in place to mitigate risks and keep people safe. However, not all risks for people’s individual needs had been documented. For example, there was a potential risk that a staff member who is not familiar with the person may be unaware of their high risk of falls and may not provide the appropriate support level to them.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. For example, equipment had not been routinely checked to ensure it was safe to be used, such as lifting equipment. The environment of the service, areas of improvements were identified in regard to auditing and recording safety checks in a timely manner, improvements to auditing were in the process of being implemented during our visit. The home was clean and well maintained and areas free from hazards, it was a calm relaxed environment. One relative told us, “Yes the home and their room is kept clean and tidy.” Another relative told us, “They have a beautiful room and lots of their own possessions there.”

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. Safe recruitment procedures were in place. New staff underwent and induction and training programme. They told us they were confident with the level of training they had received. We viewed training records and staff were up to date with their mandatory training. We observed sufficient staffing numbers on both days we visited, and staff were attentive to people in the communal areas and in their rooms. Staff told us, “I think we have enough staff, we don’t use agency.” One relative told us, “There is no massive turnover of staff which helps. They have a call bell in their rooms. It seems ok.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Personal Protective Equipment (PPE) was available around the home and staff were observed using PPE appropriately. Staff had Infection Prevention Control (IPC) training. There was an outside agency used for regular weekly cleaning hours. The registered manager did audits of cleaning checklists. One relative told us, “Yes, it is a beautiful home and always smells fresh.” One person told us, “My room is nice and clean.”

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. Staff demonstrated good knowledge of what medicines were and what they were for. We observed staff administering medicines, they were competent and patient with people and completed the Medicine Administration Records (MAR) charts appropriately. Stock checks were carried out and the home had recently implemented a new medicines auditing system which was working well.