Churchfield Court

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 changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. The service was in breach of legal regulation in relation to people’s safe care and treatment, safeguarding and staffing.

This service scored 59 (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. Lessons were not always learnt to continually identify and embed good practice. Learning from feedback from visiting professionals was not always fully implemented. For example, where partner agencies had visited the service and given feedback, actions had not always been taken to address their concerns. Some of the concerns we identified during our visit had previously been noted by visiting professionals. For example, the importance of maintaining accurate records of people’s fluid intake where required, which is essential to maintain people’s health.

Staff told us some learning from incidents was shared with them in staff meetings so that changes could be made to people’s care and support if required.

The provider worked with people and healthcare partners to establish and maintain safe systems of care. They made sure there was continuity of care, including when people moved between different services. There were systems in place to ensure people’s needs were assessed before moving into the home. Following this care plans were developed to provide guidance for staff to follow when supporting people. The staff team worked alongside other professionals to ensure people’s needs were understood and met across a range of other community services, for example, mental health or community nursing teams.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. However, where people’s rights were restricted, although the provider had assessed their capacity to make specific decisions, they had not applied for Deprivation of Liberty Safeguards (DoLS) which are required to ensure any restrictions are lawful.

However, people told us they felt safe and had confidence staff would protect them from harm. One person said, “I feel very safe they are all very kind.” Staff had received training in safeguarding and were able to identify signs of potential abuse. Staff we spoke were confident to escalate any concerns for people’s safety or well-being and knew how to report concerns outside of the home’s management team. For example, staff told us they knew how to report safeguarding concerns to the local authority. The management team had established processes to ensure any concerns for people’s safety were appropriately referred and reported and action was taken to protect people from potential harm.

The provider did not always work well with people to understand and manage risks.

Risks associated with hydration were not effectively managed. For example, where people’s fluid intake required monitoring due to their health needs, this was not always recorded or managed well. Records showed staff had recorded basic information about people’s fluid intake, but records were not detailed enough to enable the management team to check if people were drinking enough, or too much. In addition, there was no oversight of these records so if a person did not drink enough, staff may not be aware, and therefore action may not be taken to improve the person’s health.

Following the inspection the registered manager confirmed systems had been introduced to ensure people’s fluid intake was effectively monitored.

Other risks to people’s health and safety we assessed and recorded, offering guidance to staff about how to safely support people. Staff we spoke with were aware of how to support people in line with their care needs and told us any changes were shared with them during staff handover meetings. A staff member told us, “If someone goes to hospital, I always document what the doctors tell us. That way I can inform the staff team so the person’s risk is managed."

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The home environment was safe for people and we observed staff using equipment, such as mobility aids, in a safe way. Audits were regularly carried out to ensure people’s safety. We reviewed health and safety audits and found where concerns were identified, action had been taken or was underway to improve the environment.

The provider did not always make sure there were enough qualified, skilled and experienced staff available to meet people’s preferences in relation to their care.

Some people we spoke with felt there were not enough staff. People shared examples of the impact of this including not being able to go out, not having anything to do or anyone to talk to. Other people spoke about not being able to have personal care as often as they would like to. One person told us, “I have a shower every three days. I would like one more often but there’s not enough staff.” Another person commented, “I can have a shower when I want one but only twice a week, there’s not enough staff for more.” Staff also told us there were times when they felt more staff were needed to ensure people’s needs were met in a timely way. Where people did not receive support to shower, they were supported by staff with washing to maintain personal hygiene.

We observed staffing levels throughout the day and found there were long periods of the day where staff were not present in communal areas. During lunchtime staff brought lunches to people but then there was no staff presence in the dining room for the duration of lunch.

Staff had received a range of training to provide them with the skills and knowledge required to meet people’s care and support needs. However, one person had recently been diagnosed with epilepsy and staff told us they had not received training in supporting people with epilepsy. Some people living at the home had mental health needs and although staff had received basic training in this area they had not been trained specifically in relation to people’s diagnoses. This may mean people do not receive support that meet their individual needs. Following the inspection the registered manager told us there were plans in place to ensure staff received training in these areas. Recruitment checks had been carried out to ensure staff were safe to work with people.

The provider assessed and managed the risk of infection. One person told us, “It’s all very clean in here.” Another person said, “The cleaning here is brilliant.” We observed the home environment which was clean and free from odours. Personal Protective Equipment (PPE) was available throughout the home, and staff had received training in infection control to reduce the risk of cross infection. The management team completed regular audits to assess the risk of infection. Where concerns had been identified, action had been taken to improve the environment.

The provider did not always make sure that medicines and treatments were safely managed. For example, where people were prescribed pain relieving transdermal patches, staff had not followed best practice guidance and completed records to show where these were applied. This placed people at risk of receiving their medicines inconsistently, or not as prescribed. Where people refused medicines, staff had not always sought the advice of healthcare professionals to ensure any associated risks were safely managed.

Despite these concerns people told us they were happy with the support they received with their medicines. One person said, “They [staff] are spot on with my medication. I’m very safe here because I get my medication.”

Medicines were stored safely. Where people were prescribed ‘as required’ medicines there was guidance in place for staff to follow to ensure these were given safely. Staff who administered medicines had received training and their competency was checked to ensure they were safe to administer people’s medicines.