The Churchley Rest Home Limited

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The provider was in breach of legal regulation in relation to good governance. Audits had not been routinely carried out in line with the providers polices and procedures.

This service scored 61 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. Whilst there was no formal defined documented culture or vision for the home, it was evident staff knew people well and what was important to them. The manager was held in high regard by both staff and people living in the home. One staff member told us, “You cannot fault the care we give, we make sure we do all we can for the residents. This is a caring home, I know it’s a cliché, but we are like a big family and that comes across in what we do.” Another staff member told us, “This is a good home, it’s very caring, we want the best for the residents. I like working here.”

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty. Feedback from staff and people clearly showed that the registered manager was compassionate and put the care of people and the support of staff at the forefront of his role. However, shortfalls in the systems and processes we viewed demonstrated that there were areas for improvement in the management and governance. For example, Care plans had not been reviewed for a significant period of time, audits and systems of quality had not been developed or carried, day to day checks and legal requirements at the home had not been routinely followed.

Community health professionals told us how they had offered support, guidance and training opportunities previously and the management team had not engaged with this support. The management team were lacking knowledge and understanding around carrying out MCA’s and which people might need to be considered under DoLS, this support and guidance is now in the process of being provided. One staff member told us, “The registered manager is very good, they are really caring, and [Senior carer] is making some good changes. They ask us what we think and is there anything they can do for us.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. There was a whistle blowing policy in place and staff knew how to raise concerns. Staff told us, “I would raise any concerns with the manager, he would listen to me, we take care of everyone here.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. One staff member told us how they were able to practice their religion and special adaptions were made for them around certain religious times of the year. Staff feedback was that they felt supported and involved in the service and would happily raise any issues with management. A member of staff told us, “I can go to [registered manager] with any problems I have, he would listen and help, I’m sure of it. I definitely feel supported.”

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. For example, people who required DoLS authorisation had not been assessed for this and this posed risk to them leaving the home without support and potentially coming to harm. Regular audits and checks had not been carried out, although in place these were not routinely carried out. Policies and procedures were in place, however these have not been followed in respect to notifying the CQC of events, following safeguarding procedures, assessing people’s capacity, care planning and governance. Improvements had been identified, and the management team was in the process of increasing audit checks, however time was needed for this to be fully embedded and audits to be fully updated. The management team told us, the audits had not been carried out routinely and that they were in the process of making changes to ensure these were updated routinely in line with the services policies and procedures. However, due to regular audits not having been routinely carried out, potential risks could have occurred. For example, due to a lack of audits on lifting equipment being serviced, this could have led to the equipment failing whilst an individual was using this equipment.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and communicated with partners. We saw people accessing the local community as they pleased and health professionals and a local nursery visited the service. There was a wide variety of activities for people to engage in should they wish to. One person told us, “We are not made to do anything, we are free, we can go out as much as we want to. On the whole I like it here.”

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research. We saw no evidence of systems to develop learning, improvement or innovation that were in place or being used. The management team told us they had some systems of learning and assessing the competence of staff, but these had not yet started. Improvements were identified in the induction and learning and development of staff. Ongoing improvements were being implemented but were not fully embedded.