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 the previous assessment 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 policies and procedures.

At this assessment, enough improvements had been made, and the provider was no longer in breach of regulation.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 75 (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. There was an open and positive culture and staff enjoyed working at the home. Regular staff surveys were carried out to ensure staff views were heard. Regular staff meetings took place to give staff the opportunity to share ideas and discuss any concerns.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. Previous areas requiring improvement identified at the last inspection had been met in respect to the management team not engaging effectively with community professionals and other providers. The registered manager told us how they now attended regular provider forums, went to regular meetings with other providers and shared experiences and information. The registered manager told us they found this beneficial. They said "We are proud of the progress our service has made over the past year, particularly in developing the knowledge, skills and confidence of our staff and the positive impact this has had on the people we support."

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. Staff told us there was an open-door culture and the management team always had time to talk and listen to them. Managers told us, they were always available to talk to staff and people.

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. Staff told us they were treated well, and their equality and diversity respected. Staff described working at the home as a family culture and described the good teamwork and how they respected each other.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. Previous areas requiring improvement identified at the last inspection had been met in respect to audits and systems of governance not been routinely carried out. Additionally, policies and procedures had been in place, however these had not always been followed. The management team now had effective quality assurance oversight and carried out regular audits and checks to monitor and improve all aspects of the home and care delivery.

The registered manager told us how they had regular quality assurance meetings. These had been effective in highlighting areas of improvements and ensuring issues were rectified. Policies and procedures were in place, which were regularly reviewed. Staff recognised the recent improvements and felt these were positive.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. The management team worked in collaboration with community professionals to ensure people could access community support when they needed to. Staff told us how personalised people’s end of life care to reflect their individual needs.

The registered manager gave us an example of collaborative working and told us, “Although it was a sad time, we are also proud of the compassionate care we provided to a resident during their final days of life. Staff worked closely with the GP, community nursing teams, advanced care practitioner and district nurses to ensure their wishes and comfort remained at the centre of their care. We introduced an end-of-life comfort box containing essential items to support dignity and comfort, and the resident was able to spend their final hours surrounded by close friends, some of whom remained with them throughout the night. The teamwork, compassion and respect shown by everyone involved reflected the values we strive to deliver every day.”

Community professionals told us, "The manager now actively participates in the local care home forums and attends care home enrichment meetings, providing opportunities to share learning, experiences, and good practice with other care home managers."

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research. Previous areas requiring improvement identified at the last inspection had been met in respect to there not being systems in place to develop learning, improvement or innovation.

Staff spoke with confidence of the new training they had received and how they found this beneficial and were able to apply this knowledge when supporting people.

The registered manager told us, "One significant achievement has been improving our team's understanding of dementia care. We arranged for an external trainer to provide specialist training and practical guidance, enabling staff to better understand dementia and respond more effectively to behaviours of distress and changes in residents' needs."

Community professionals told us, “The home maintains regular contact with us for advice and guidance, and effective professional relationships have been developed.”