Church View Nursing Home

Church View is a care home providing personal and nursing care to 36 older people at the time of the inspection. The service can support up to 43 people.

People’s experience of using this service and what we found

The service ensured arrangements for social activities met people’s individual needs and followed best practice guidance, so people could live as full a life as possible. The provider used a pool activity level (PAL) instrument to providing activity-based care for people with cognitive impairments, including dementia. The service had explored to find out what people had done in the past and evaluated whether it could accommodate activities.

The management team and staff ensured people received personalised care which had positive impact on their lives. Visiting professionals told us the service was focused on providing person-centred care and support and achieved excellent results. For example, one person had improved, and they were going home to live independently. Staff knew people well and quickly identified people’s changing needs.

The service worked closely with healthcare professionals and provided good end of life care. People experienced a comfortable, dignified and pain-free death. We saw feedback from relatives following end of life care was positive. There was a rapid response to people’s changing care needs and advice on care and support for people and staff at the times they needed. The home had established close links with a local hospice. Staff had the specific skills to understand and meet the needs of people and their families in relation to emotional support and the practical assistance they need at the end of the person’s life. Records showed staff had attended end of life care training. Staff told us they were supported by the management team with empathy and understanding.

People living at Church View told us they received safe care from skilled and knowledgeable staff. Staff knew how to identify and report any concerns. The provider had safe recruitment and selection processes in place.

Risks to people's safety and well-being were managed through a risk management process. There were sufficient staff deployed to meet people's needs. Medicines were managed safely, and people received their medicines as prescribed.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. People were supported to maintain good health and to meet their nutritional needs.

People told us staff were caring. This ethos consistency enabled people to receive good care from staff who knew them well. Staff did all they could to promote independency and we saw examples of such practices.

The home was well-led by a registered manager who was focusing on improving people’s care and developing staff skills. A lot of significant changes had been implemented to support effective team working and improve people’s outcomes. The service had a clear management and staffing structure in place and staff worked well as a team. The provider had quality assurance systems in place to monitor the quality and safety of the service.

Rating at last inspection and update

The last rating for this service was requires improvement (published 15 January 2019).

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

This inspection was brought forward, as we had received a high number of anonymous concerns about the service. The concerns generally related to people not having adequate food and fluids or being sufficiently repositioned, to minimise their risk of pressure ulceration. Senior managers within the organisation investigated the concerns and found them largely unsubstantiated. One concern identified shortfalls in the completion of care intervention charts. The incomplete records did not evidence people had received the care they required.

The service had a poor history of non-compliance in areas such as the planning of people’s care and the safe management of medicines. In 2015, the service was rated inadequate and placed into special measures. In 2016, we imposed a condition on the provider’s registration, as shortfalls continued and improvements were not sustained. The provider has adhered to the condition and sent us the information we required. During subsequent inspections in 2017 and January 2018, further improvements were made but these were not consistent to demonstrate a good service. Senior management told us the home was one of the services within the organisation that was not where they wanted it to be. They said the abilities of previous managers had contributed to this.

There was not a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

A new manager had started employment at the service in September 2018. They were being supported by a manager who was the registered manager of another service, within the organisation. Both were planning to become registered managers of Church View Nursing Home. At the time of the inspection, applications to do this had not been submitted.

At this inspection, we identified some equipment which compromised good infection prevention and control. This included a shower chair that had rust on its frame and a foot operated bin that had broken. Records to demonstrate the laundering of people’s hoist slings had not been completed although the format to do so was in place. Staff addressed these areas by the end of the inspection.

There were a range of audits to assess the quality of the service. Monthly management reports were undertaken and sent to senior managers for further analysis. Whilst many areas were assessed, the audits had not identified the shortfalls found at this and previous inspections.

Improvements had been made to the safe management of people’s medicines. The medicines were stored securely, receipted and disposed of appropriately when no longer required.

Some risks to people’s safety such as those associated with falling and pressure ulceration had been identified. Records showed measures were in place to minimise the risks. Other areas, including one person’s risk of choking and accidents with equipment, had not received sufficient focus.

Each person had an electronic care plan in place. The information was generally well written and regularly reviewed. However, some aspects of people’s health care needs and the support required, was not clearly documented.

Not all staff had completed the training expected of them. Management had identified this and were reminding staff of their responsibilities to complete allocated courses. Records showed the completion of training was an “improving picture. Staff had one to one meetings with their manager to discuss their work. They were being given clear information about accountability and the standards expected of them. Action had been taken in response to any shortfalls in practice.

Improvements had been made to decision making in line with the Mental Capacity Act 2005 (MCA). Assessments of a person’s capacity had been completed yet documentation to evidence this was not consistently written. Staff were aware of the principles of the Act and how they applied them in practice.

There were sufficient staff to support people although feedback about staffing levels was variable. During the inspection, the home was calm and call bells were answered promptly. People were not waiting for assistance.

People had enough to eat and drink. They were offered choice and a range of snacks between meals. Any weight loss was monitored and discussed with relevant professionals.

People and their relatives were happy with the care provided and complimentary about the staff team. People felt safe and their rights to privacy and dignity were maintained.

There have been five inspections of this service since the beginning of 2015. In May 2015, four warning notices were issued, the service was rated inadequate and placed in special measures. Improvements were seen in October 2015 but at the inspection in March 2016, not all had been sustained and further shortfalls were identified. Due to this, we imposed a condition on the home's registration. This required the provider to undertake regular monitoring of the service and inform us of their findings. The provider has fully complied with the condition and sent us the information as required.

The last inspection of this service was on 25, 26 January and 2 February 2017. Improvements continued to be made but we issued a requirement notice in relation to Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations. This was because decision making, for those people who did not have capacity, was not always undertaken in line with the Mental Capacity Act 2015. At this inspection, improvement in this area had been made. However, documentation did not always clearly evidence the best interest decision making processes, which had been undertaken.

Church View Nursing Home is registered to accommodate and provide nursing care for up to 43 people. If the twin rooms were used for single occupancy, 36 people could be accommodated. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. On the day of our inspection, there were 33 people living at the home. Church View Nursing Home has bedrooms on the ground and first floor. All rooms have en-suite facilities. A passenger lift is available for people with mobility difficulties. There is a communal lounge and dining area on each floor with a central kitchen and laundry room.

There was a manager in post. They had worked at the home for approximately seven months and were in the process of registering to become the registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The manager and another manager who was also in the process of registering, to become the registered manager, were both available throughout the inspection.

People’s medicines were not safely managed. Whilst administering medicines, the staff member did not ensure safe practice. This was because they gave the medicines to another member of staff to give to the person. One medicine was inaccurately labelled, which had not been identified and another was out of date. Another person had not received their night time medicines but staff had recorded they had been given.

A range of audits were in place to assess the quality and safety of the home. These assessed areas such as infection control, health and safety, medicines and the dining experience. There was a continuous improvement plan and the manager submitted a monthly management report to senior managers. However, whilst these structures were in place, the shortfalls we identified particularly with medicines, had not been identified.

Staff were happy with the amount of training they received and felt well supported. They were aware of their responsibilities to keep people safe and to report concerns as required. Training records were in the process of being developed as they did not effectively show what courses staff had completed.

Improvements had been made to people’s care plans. The support people required to meet their clinical needs was well written. Wound treatment plans were clear but other areas of people’s support were less detailed. There was limited information about a person’s resistance to care and the use of restraint. New initiatives were being implemented to develop more person centred care plans.

The support people received had improved. Care plans gave staff clear information about reducing people’s risk of pressure ulceration. Staff had fully completed care charts to evidence the support they gave. All pressure relieving equipment was set correctly and regularly checked.

People enjoyed the food and were supported to have enough to eat and drink. People had a choice of food and alternatives were provided, if they did not like what was on the menu. Records showed those people at risk of malnutrition or dehydration, were given additional support and their intake was regularly monitored. Concerns were reported to the required healthcare professionals.

There were sufficient numbers of staff to support people effectively, although there was some reliance on agency staff. Successful recruitment was addressing this. Staff were not rushed and answered call bells in a timely manner. The home was calm and relaxed. The majority of people, relatives and staff told us there were sufficient staff available.

People and their relatives were complimentary about the cleanliness of the home. All areas, including those less visible, were clean and there were no odours. Effective cleaning schedules were in place and staff were aware of procedures to minimise the risk of infection. A system for the laundering of hoist slings was implemented when it was brought to the manager’s attention.

People spoke about staff and their caring nature, in a positive manner. Staff were friendly, caring in their approach and respected people’s privacy and dignity. There were positive interactions and some light hearted banter, which people responded to well.

We found two breaches in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. One of these was repeated from the last inspection. You can see what action we told the provider to take at the back of the full version of the report.

Church View Nursing home is registered to accommodate and provide nursing care to up to 43 people. If the twin rooms were used for single occupancy, 36 people could be accommodated. On the day of our inspection, there were 34 people living at the home. Church View Nursing Home has bedrooms on the ground and first floor. All rooms have en-suite facilities. A passenger lift is available for people with mobility difficulties. There is a communal lounge and dining area on each floor with a central kitchen and laundry room.

In May 2015, a comprehensive inspection identified the service was not meeting a number of regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because care was not consistently delivered in a safe and effective way and there were not always enough staff to effectively meet people's needs. In addition, quality auditing systems were not identifying shortfalls in the service. We issued four warning notices to the provider, as a result of the concerns we identified and the service was rated as inadequate. The service was placed into special measures. Special measures provides a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

In October 2015, we completed a focussed inspection to ensure improvements had been made. We found the provider had taken the immediate action necessary to improve the service. Another comprehensive inspection was undertaken in March 2016. Not all improvements had been sustained and further shortfalls were identified. Insufficient improvement had been made to enable the service to come out of special measures. As a result of this, we imposed a condition on the home’s registration. This required the provider to undertake regular monitoring of the service and inform us of their findings.

The registered manager who was in post at the last inspection, left the company in October 2016. A new manager was recruited and started employment shortly after the previous manager left. This manager was available throughout the inspection and was in the process of registering with the Care Quality Commission, to become the registered manager. In addition to the manager, two senior managers including the Director of Operations and a supporting manager, were present during the inspection.

During this inspection, clear improvements had been made to the service. The manager and senior managers had taken the home “back to basics” and were confident the service was now safe, with effective leadership. Time was required to embed the changes and further work was being undertaken to offer care, which was more person centred. There had been additional training to develop staff’s knowledge and more sessions were planned. Staff had been given an area of specialism, such as end of life care, which they were in the process of developing. Focus was being given to recruitment, to minimise the use of agency staff.

New systems and processes had been implemented. This included a comprehensive range of audits and on-going monitoring. The audits were working well and clear action plans were in place to ensure any shortfalls, were appropriately addressed. However, some aspects of service provision had not been identified as requiring additional focus. This included ensuring those people, who did not have the capacity to make certain decisions, were appropriately supported in line with the principles of the Mental Capacity Act 2005. After the inspection, the manager sent us documentation to show arrangements had been made for mental capacity assessments and best interest meetings to be undertaken.

A range of meetings had been introduced to ensure staff were fully informed and aware of their responsibilities. Staff felt well supported and were appreciative of the improvements, which had been made.

Improvements had been made to the management of risk and people’s safety. This was particularly apparent in the monitoring of people’s food and fluid intake. There were assessments, which identified potential risks and what action was required to manage them. However, one person was given an ‘ordinary’ meal at lunch time, when they required a soft diet. This increased the risk of them choking. Another person was prescribed a thickener for their drinks but this was not stated on their care plan. Clear focus had been given to the management of people’s skin and the prevention of pressure ulceration. Records showed effective management of any wounds.

The planning and delivery of care had been improved upon. People looked comfortable and well supported although one person had stained clothing and another had fallen asleep over their breakfast. Staff had not provided these people with the support they needed. Care plans had been updated and were generally reflective of people’s needs. However, information about continence and the care people wanted, whilst nearing the end of their life, lacked detail. This gave staff limited information about people’s needs in these areas.

Improvements had been made to the management of people’s medicines. However, there had been two errors in November 2016, where people had been given the wrong dose of their medicines. In addition, a relative stopped a member of staff from administering a dose of insulin, when it had already been given. All errors were appropriately managed although it was clear that staff had not followed procedures, for the errors to have occurred.

There were sufficient staff available to meet people’s needs. The numbers of staff required during the day and night had been reviewed and amendments made. Consideration had been given to the deployment and skill mix of staff. Staff confirmed additional staff were deployed or the manager worked “on the floor” to assist, when required. Staff answered call bells and undertook people’s requests, in a timely manner. They went about their work without rushing.

People told us they liked the food and had enough to eat and drink. There were positive comments about the quality and variety of food. Focus was given to those people at risk of losing weight. People told us they felt safe and liked the staff. Established relationships had been built and staff spoke about people with fondness. Staff gave people time and interacted in a friendly, caring and attentive manner. People’s rights to privacy and dignity were maintained.

We found one breach in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we required the provider to take at the end of this report. However, due to the overall improvements which had been made, the service has been removed from special measures.

At the last comprehensive inspection in May 2015, we identified the service was not meeting a number of regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because care was not consistently delivered in a safe and effective way. In addition, there were not always enough staff to effectively meet people’s needs and quality auditing systems were not identifying shortfalls in the service. We issued four warning notices to the provider as a result of the concerns we identified and the service was rated, as inadequate. The service was placed into special measures. Special measures provides a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made. The provider placed a voluntary embargo on admissions to the home, whilst they made the required improvements.

We completed a focussed inspection in October 2015 to ensure improvements had been made. We found the provider had taken the immediate action necessary to improve the service. During this inspection in March 2016, we found the provider had sustained some improvements but not all. Due to this, there was not enough evidence to enable the service to be removed from special measures. Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

Church View Nursing Home provides accommodation to people who require nursing and personal care. The home is registered to accommodate up to 43 people. If the twin rooms were used for single occupancy, 36 people could be accommodated. On the day of our inspection, there were 28 people living at the home. Church View Nursing Home has bedrooms on the ground and first floor. All rooms have en-suite facilities. A passenger lift is available for people with mobility difficulties. There is a communal lounge and dining area on each floor with a central kitchen and laundry room.

The registered manager has worked at the home since November 2014. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager was present throughout the inspection.

There were not enough staff to effectively meet people’s needs at all times. On the first floor, the atmosphere felt rushed. Some people received little stimulation and others needed to wait for their requests to be fulfilled. Staff told us staffing levels were often insufficient and at times, negatively impacted on the care they could give. There were occasions due to staff sickness at short notice, when staffing levels fell below the recommended level, as set by the provider. The registered manager and operations manager did not agree that staffing levels were insufficient to meet people’s needs. They had however planned to deploy an additional member of care staff each day, to meet the increased number of new people being admitted to the service.

Improvements had been made to the support people received to minimise their risk of pressure ulceration. Assessments identifying the risk of ulceration were in place although these were not all reviewed at the recommended frequency. Care plans generally identified the support people needed yet not all wounds had clear treatment plans in place. Records generally showed people were repositioned within the recommended timescales although there were some variations. Records did not show people had been sufficiently supported with their continence care and symptoms were not being addressed. Not all pressure relieving mattresses were on the correct settings according to people’s weight.

Some improvements in relation to maintaining people’s nutrition and hydration needs had been sustained but this was not apparent for all. Staff had completed food charts more consistently to monitor people’s food intake, although snacks and supplement drinks were not always documented. Fluid charts gave greater detail about the person’s recommended daily fluid intake and the information was monitored by staff, on a regular basis. However, the records did not show additional fluids were promoted, when required. Not all people on the first floor were sufficiently supported to drink.

Assessments had been undertaken to minimise potential risks such as moving people safely. However, the information did not always inform staff how to minimise the risk effectively. People told us they felt safe and were comfortable in the vicinity of staff. Staff had or were in the process of undertaking training in relation to keeping people safe. Focus had been given to staff training as a whole, so improvements had been made in this area. Staff were generally up to date with those courses, which the provider classed as mandatory. Other training was in the process of being arranged. Individual meetings with staff were taking place to discuss their practice and any concerns they might have. Staff felt well supported within the team although there were some issues with low morale and staff not feeling properly valued by the management team.

Improvements had been made to the safety of people’s medicines although some shortfalls were identified. The medicine administration records were more accurately completed although records did not always show people’s topical creams were applied, as prescribed. One medicine was not appropriately stored and a trolley storing medicines was not always kept securely. Information had been developed to inform staff of the prescription of “as required” medicines but staff did not have access to up to date medicine reference guides.

The registered manager had completed monthly management reports, which showed an up to date portrayal of the home. Accidents were being analysed to show possible triggers and trends to minimise further occurrences. Additional quality audits had been introduced and were identifying some issues. However, the audits had not identified or satisfactorily addressed shortfalls, which were found during this inspection. This particularly applied to the system of serving drinks to people, which was clearly not working and not listening to staff and recognising the impact of insufficient staffing. The registered manager told us staff had worked hard to make improvements to the service. They believed the home was now in a “much better place” than it was previously although recognised there were day to day issues, which needed on-going attention. The registered manager confirmed that developing the home and maintaining the improvements made so far, were an important area, which would be given key focus.

People told us they enjoyed the food and those who required assistance to eat were supported in an attentive manner. There were positive interactions between staff and people who used the service, which was an improvement from the last inspection. Staff spoke to people in a caring, friendly and respectful manner. They promoted people’s privacy and dignity and spoke about individuals with fondness. Staff were aware of people’s needs and were committed to providing a good standard of care. People felt safe in the vicinity of staff and were aware of how to make a complaint. Systems were in place to enable people and their families to give feedback about the service they received.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and of the Care Quality Commission (Registration) Regulations 2009. We are taking further action in relation to this provider and will report on this when it is completed.

People who lived in the home we spoke with told us they were well cared for and that the staff were friendly and respectful. We were told that care was carried out in an unhurried and professional manner. People told us they enjoyed the food and the activities. We saw that several new activities were being organised during the week and at the weekends.

We found that improvements had been made to the way staffing was organised to ensure people's needs were met.

We found that improvements had been made to the planning and monitoring of staff training and that regular staff meetings were being held. Staff were well supported by the senior staff, the nursing staff and the manager but some were not receiving sufficient formal supervision.

Relatives we spoke with said the staff were helpful and caring but were "often rushed off their feet" and "too busy to spend time with people".

We observed that some people were not always provided with regular drinks and that there were insufficient staff available during the morning to get everyone up at a time of their choosing.

We observed that the staff team worked hard to meet the personal care needs of people and this work was done to a good standard. However once people were brought to the communal areas of the home there was a lack of engagement and stimulation. This was partly due to a lack of activities.

We found that the home provided training for staff but was unable to provide robust evidence that all the required training had been completed and the required refreshers undertaken.