Churchfield Court

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 good. At this assessment the rating has changed to 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 service was in breach of legal regulation in relation to governance at the service.

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 culture based on promoting independence and understanding challenges and the needs of people. However, in some cases the provider had not fully considered people’s needs when developing the service or operating it on a day-to-day basis. For example, some people living in the home had specific needs that were not being met due to the service not being designed to meet their needs. For example, specific mental health needs, or needs relating to a learning disability. We found staff knowledge in these areas was not always in line with best practice and therefore people’s care experience could be improved. We discussed the vision for the home with the registered manager who told us they would review this with the provider and ensure the service provided met the needs of people living at the home.

Not all leaders understood the context in which the provider delivered care, treatment and support. There were processes in place to identify which members of the management team held responsibility in specific areas. However, leaders had not always acted to ensure the service operated within the law. For example, staff we spoke with understood people’s capacity to make specific decisions and knew where people were being unlawfully restricted. However, the management team, and those representing the provider, who were responsible for governance, had not ensured those restrictions were being carried out lawfully.

Despite the concerns people raised about food and activities they spoke positively about how the home was managed. One person told us, “The management are alright. I spoke to [name of registered manager] this morning. He comes and talks to us.”

Staff were supportive of the management team and the provider and told us they felt supported in their roles. One staff member commented, “[Name of deputy manager] is very supportive. They and the senior care staff are who I go to. I think the home is well run."

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. People told us they felt able to express their views about their care. Staff we spoke with told us they could speak openly in staff meetings and one to one meetings with the management team. One staff member said, “[Person’s name] offers their time. I could speak with them. They are approachable and easy to contact."

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 felt they were treated with respect and work was allocated fairly across the staff team. They shared examples with us of how the provider and management team had supported them personally giving consideration to their diverse needs.

The provider did not always have clear systems of accountability or good governance. Although audits to monitor the quality of care were completed, these were not always effective in identifying areas of concern noted during our inspection. For example, medicines audits had not identified the inconsistencies with administration we observed. Despite the registered manager being aware of people being restricted within the home they had not submitted applications to ensure this was legally authorised. We also identified concerns about the registration of the service which potentially impacted on the quality of care people received.

Following the inspection the registered manager confirmed they had responded to feedback provided during our inspection and had begun to implement changes to drive improvement and address areas of concern. We will review the effectiveness of these changes next time we inspect the service.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information with partners.

The provider worked in partnership with local health organisations to meet people’s changing needs. Staff shared information with health professionals to support people to receive responsive individualised care. A recent visit by a local authority had identified required actions and we found the provider was taking action to make any required improvements.

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.

Although people’s independence was promoted, the provider had not always considered how they could improve the quality of life for people. People told us their lives were significantly impacted by a lack of support to engage in positive activities and interests. Best practice guidance had not always been considered for people with needs associated with a learning disability or their mental health. Innovative ways of supporting people had not always been considered, which meant staff did not always have the knowledge required to promote people’s quality of life through individual interaction and support.

Following the inspection the registered manager told us, “My goal is to provide reassurance, strengthen communication, and be more actively involved in the daily routines to further enhance the quality of care and support we provide to our residents."