Church View - Princess of Wales Community Hospital Also known as Church View

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 people were not always safe and protected from avoidable harm.

The provider was in breach of legal regulation in relation to lack of escalation of safeguarding concerns and the management of choking risks.

This service scored 56 (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, based on openness and honesty. Staff did not always listen to concerns about safety or investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

We reviewed body map records and found that unexplained injuries were not always investigated and reported to the appropriate external agencies. Lack of investigation meant that there may have been missed opportunities for learning and improvement. After raising concerns with the provider, they agreed to develop a written protocol as clear guidance for staff and scheduled a team development day to discuss any gaps in knowledge.

Although we were not assured concerns about safety were always investigated and reported, staff we spoke with felt confident in raising concerns with the provider. One staff member told us, “I always feedback on the service… If I disagree with something I will always feedback, I feel like management listen.” We saw evidence that learning is shared in team meetings and handovers.

People had access to professionals, family and friends outside of the service they could raise concerns with about their safety. A relative told us, “[The service] gives me lots of feedback, any concerns they’ll tell me. They’ll listen if I have concerns, but I don’t have any”.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Staff told us they were provided information about people from the local authority and used this to determine whether the service was appropriate to support each individual. One relative told us, “[Person’s family] had 3 visits in transition, we go in, have a chat, and showed staff how to support [person] on visits.”

Staff completed telephone pre-admission assessments prior to each stay to check people’s health and any changes in need. The service had introduced body maps to be completed prior to the person’s stay as part of the handover protocol, to keep track of injuries, rashes, pain or other areas of concern to meet people’s health and wellbeing needs. However, we found body maps were not routinely completed by family members, and the service had not followed this up. A senior staff member told us it was a difficult topic to raise with people’s families. The Service Lead told us they would take action to address this.

There was a lack of clarity for relatives on the process if the person using the service became physically unwell and required medical intervention. One relative told us, “Nurses waste time, they should be calling 111, out of hours GP but instead ring [relatives] to come and collect [person].” The provider had a protocol in place for deteriorating physical health which included seeking the appropriate medical intervention. However, some relatives felt that the provider was not following this protocol and therefore the period of respite was cut short.Following the inspection, the provider clarified that medical services would be contacted where clinically indicated, but that individuals who became unwell and required increased observation or support may need to return home as this level of care was outside the scope of the service.

The service did not have effective safeguarding systems to help protect people from abuse. Safeguarding concerns were not always identified or reported to the appropriate organisations.

The service did not consistently take action to safeguard people in relation to unexplained injuries and marks. Body map records between May and August 2025 documented bruises, scratches and spots in relation to two people. There was no evidence these episodes were reported, reviewed, investigated or referred to the local safeguarding authority as required. In response to our concerns, the provider told us there was not enough information for them to accurately manage the incidents. Senior leaders said they felt confident health and care staff would have acted to make a safeguarding referral where necessary at the time. We raised our concerns about this response and the provider agreed to discuss the unexplained injuries with the local authority safeguarding team, who advised them to submit safeguarding referrals and to inform people’s social workers. The provider confirmed this was acted upon and they took immediate action to review and communicate their safeguarding processes with staff and people families. Further staff safeguarding training was also arranged to lessen risks to people.

In response to a separate incident regarding staff unsafe practice against a person’s eating, drinking and swallowing guidelines, the provider decided that it did not meet the safeguarding threshold for referral because the person hadn’t come to harm through choking. We were concerned the provider had not considered the risk of harm. Following our feedback the provider contacted the local safeguarding authority who advised them to submit a referral to ensure the person’s safety was fully protected.

We found restrictions placed on people were not always identified by the service or assessed and monitored as proportionate, necessary and a last resort. For example, a locked kitchen gate was used for one person to restrict their access to the kitchen. Staff told us this was to prevent risk of harm however it was not recorded in the person’s care plans or risk assessments. We observed the same person being physically obstructed by a staff member who positioned themselves in the person's way to prevent access to a particular area and to avoid a delay in them attending their day service. Whilst staff told us this was intended to minimise distress and avoid escalation, we were not assured this was a proportionate response and it was not an agreed physical intervention. This was a restriction on the person’s rights and put the person and staff member at risk of harm. One person’s care plan stated staff should use restraint if the person was in danger of harming themself but did not provide details about what trained technique should be used. The deputy manager and the service lead for learning disabilities told us no restrictive physical interventions were used at the service; however, they described staff were trained in “low level holds and blocks”. We received assurances from leaders of the services that they were taking action to review training content and communication to staff about identifying restrictive practices.  

When people lacked capacity to consent to their care arrangements, applications for Deprivation of Liberty Safeguards (DoLS) authorisations had been submitted where required. At the time of our inspection, some authorisations had not yet been granted. Records showed the provider had made the required applications, and the local authority had confirmed these were awaiting assessment and processing. Therefore, the absence of authorisations at that time was due to the local authority's ongoing consideration of the applications, rather than any failure by the provider to make appropriate referrals.

The provider did not always work well with people to understand and manage risks, and risks to people were not always assessed or reduced.

Risk assessments and care plans were in place, specifically addressing risks people could experience. Staff told us people visit the service prior to admission and risk assessments, and care plans are formulated based on information provided. One staff member commented, “We ask people and their family to come down for a visit… we go through their care plans and ask a lot of questions.” For example, we saw in one person’s care records that their behaviour could become heightened when people entered their personal space. This person’s behaviour care plan provided guidance for staff to manage this risk and how to provide a comfortable environment for this person.

However, information in people’s records were not always accurate or reflective of their current needs. For example, information in care records did not always provide accurate guidance to staff in how to safely protect people from the risk of avoidable harm.

One person’s risk assessment we reviewed did not contain any information about how to reduce the risk of aspiration and choking on fluids. Furthermore, their care plan was contradictory to the speech and language therapy (SaLT) for swallowing guidelines. Staff told us they regularly used a type of drinking vessel that was different to the equipment identified in their SaLT plan. We identified in another 2 people’s care plans that they required their food to be cut up due to difficulties with chewing and eating too quickly. However, the service had not made a referral to SaLT to assess their needs. We raised with the service and referrals were made to to SaLT. The service reviewed people’s care plans and risk assessments to make sure care plans were up to date and accurate and changes were communicated to staff in handover meetings. The provider also arranged for all staff to complete dysphagia (difficulty or discomfort in swallowing) training as essential annual training.

Staff at the service mostly detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the safe delivery of care.

Equipment was serviced to maintain safety and furniture was in a good state of repair. Equipment was available to meet a range of needs including specialist beds, hoists and accessible baths. One relative commented, “Bathrooms have all been kitted out, [person] has a TV in their room, there are gardens, it is not a hospital vibe, [the service] had a nice feel.”

However, we saw an unlocked clinical waste bin in an outdoor area behind an unlocked gate that would have been accessible to people using the service utilising the outdoor area. This was identified as a concern and the gate was locked and staff told us people using the service would be always accompanied by staff in this specific area.

We also found that health and safety audits were not always completed in a timely manner to identify and manage potential safety risks within the environment.

The provider made sure there were enough qualified, skilled and experienced staff who received effective support, supervision and development. Staff had a good rapport and worked well together.

Staffing levels were planned in accordance with the number of people attending the service and their assessed care and support needs. The service used NHS Professionals (NHSP) bank staff to cover staffing gaps when required. We reviewed an induction checklist and saw that staff were appropriately inducted into the service.

The provider’s procedures for staff recruitment ensured that they were recruited safely with the appropriate pre-recruitment checks. This included references and a check with the Disclosure and Barring Service (DBS) before staff worked with people. DBS checks provide information about details of convictions and cautions held on the Police National Computer. This information helped the provider made safe recruitment decisions.

All staff received a period of induction which gave them the skills and knowledge to meet people’s needs. Staff worked alongside more experienced staff during their induction to enable them to get to know the people using the service.

Staff had access to a range of mandatory training to provide them with the skills and knowledge required to meet people’s care and support needs. This included health and safety, infection control, equality and diversity, moving and handling, and safeguarding adults and children. Compliance rates for the mandatory training of all staff were 99% in August 2025. However, our findings at this assessment meant that we were not assured staff training was always effective in providing staff with the skills and knowledge to meet people’s needs.

Staff assessed and managed the risk of infection.

All areas of the environment were visibly clean and smelt fresh. Handwashing facilities and sanitising gel were appropriately sited throughout the building. Staff told us personal protective equipment (PPE) and all cleaning materials needed were available to them. We observed staff cleaning the environment during our visit.

The service undertook Infection, Prevention and Control and cleaning audits to identify areas of potential risk. The service achieved 97% in the most recent audit. Any areas of improvement that had been identified had an outline of the action taken and a planned completion date documented.

People using the service brought in their own medicines for respite care. There were safe systems for the appropriate and safe handling of medicines to ensure people were given their medicines as prescribed. Medicine administration records demonstrated that staff documented the route and time of medicine administration. There was an audit system of counting the receipt of all medicines and documenting any returned medicines to patients’ relatives.

People were supported to receive their prescribed medicines in a way that met their individual needs. Individual person-centred information was available which detailed people’s preference for the administration of their medicines.

Medicines storage was locked and secure with access only to authorised staff. Controlled drugs were stored safely, and checks were undertaken and recorded by two staff daily. Medicines for refrigeration were stored securely with records available of maximum and minimum temperatures to ensure safe storage. Emergency medicines and equipment were available to staff.

There was little to no regular clinical pharmacy visits at the service. The lack of regular pharmacy visits limited the oversight of medicines management.