Churchfields Nursing Home

Updated 29 April 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection, we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by 1 inspector, a specialist advisor for nursing care and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Churchfields Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Churchfields Nursing Home is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection

Registered manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

The inspection was unannounced.

What we did before the inspection

We reviewed the information we already held about the service. This included the last inspection report and notifications. A notification is information about important events, which the provider is required to tell us about by law. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make.

We used all of this information to plan our inspection.

During the inspection

We spoke with the registered manager, 6 nursing and care staff, 2 activities coordinators, the chef, the administration manager, the building manager and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We carried out observations of people’s care and support and spoke with 6 people and 7 visiting relatives for their feedback on the home.

We reviewed documents and records that related to people’s care and the management of the service. We reviewed 8 care plans, which included risk assessments. We looked at other documents such as those for medicine management and infection control. After the inspection we continued to seek clarification from the provider to validate evidence found.

Updated 29 April 2023

About the service

Churchfields Nursing Home supports people aged 65 or over, some of whom have dementia care or mental health needs. It is registered to accommodate and support up to 32 people. At the time of the inspection, 26 people were living at the home. The home has three floors with adapted facilities and en-suite rooms.

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

We found improvements had been made in the home following our last inspection. Risk assessments for people were more thorough and detailed to protect them from coming to harm. Risks such as those related to people’s health conditions and mobility were monitored and managed so staff could support them safely. Medicines for people were managed and administered safely. Safeguarding processes were in place to protect people from the risk of abuse.

The provider recruited staff appropriately and checked they were of suitable character to support people. There were enough staff working in the home. Systems were in place to prevent and control infections. Lessons were learned following accidents and incidents in the home.

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 achieve positive outcomes. They received care and support that was personalised for their needs.

People took part in activities, followed their interests and were supported to see their family and friends. We made a recommendation for the provider to look into improving the range of activities because we found some people had little to do during the day.

Systems were in place to manage and respond to complaints. People’s communication needs were met. Feedback was sought from people and relatives to help make continuous improvements to the home.

The provider and management team carried out quality audits to ensure the home was compliant with health and social care regulations and to identify areas for improvement. The management team learned lessons when things went wrong in the home. People’s dignity, privacy and human rights were respected at all times. Their equality characteristics were understood and respected.

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

Rating at last inspection

The last rating for the service was Requires Improvement, (published on 22 January 2022) and there were breaches of regulations.

We issued requirement notices to the provider for breaches of regulation 12 (Safe care and treatment) and regulation 17 (Good governance). The provider completed an action plan after the last inspection to show what they would do and by when to improve.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Churchfields Nursing Home on our website at www.cqc.org.uk

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 30 November 2021. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment and good governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions of Safe and Well-led which contain those requirements, and the Key Question of Responsive.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from Requires Improvement to Good. This is based on the findings at this inspection.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.