At the time of our inspection 36 people lived at Churchfield Court. We spoke with ten of those people, two relatives, seven staff and the provider. All of the people who lived there and their relatives were fairly positive about the home and the services provided. One relative said, 'It is ok here. They look after them'. Another relative told us, 'It is good. I do not have any concerns'. One person who lived there said, 'I like living here. I was in another home before but this one is much better'. A second person told us, 'I think it is a good place. I am happy'. The summary is based on our observations during the inspection, discussions with people who lived at the home, their relatives, the staff supporting them, and by looking at records. If you wish to see the evidence supporting our summary please read the full report.
We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask;
' Is the service safe?
' Is the service effective?
' Is the service caring?
' Is the service responsive?
' Is the service well led?
This is a summary of what we found;
Is the service safe?
All people we asked told us they felt safe. All people and relatives that we asked told us that they had not seen anything of concern. One person told us, 'The staff are not unkind'. One relative said, 'No, I have not seen heard shouting or treating people badly'.
Staff we spoke with had a basic knowledge of Deprivation of Liberty Safeguard (DoLS) processes. DoLS is a legal framework that may need to be applied to people in care settings who lack capacity and may need to be deprived of their liberty in their own best interests to protect them from harm and/or injury. We were told by the assistant manager that there had been no need to date for an application to be made to the local authority regarding a DoLS issue.
We determined that the management of day to day risks and safety was not adequate. This included the temperature control of the environment. People told us that the living areas were too hot. One person said, 'It is terrible in here'.
We found that medication systems were not safe. They placed people at risk of harm and ill health. Two people had not been given their medication as it was not available. Another person had been given the incorrect dose.
We identified that weight monitoring processes did not protect people from the risk of ill health. We found that one person had lost weight yet no action had been taken to address this.
We have asked the provider to tell us what they are going to do to meet the regulations to ensure that the service is safe.
Is the service effective?
People's health and care needs were assessed but they were not always included in detail in their care plans. Some people's needs had been overlooked by staff and had not been included in the care plan. This meant that care plans were not able to consistently support staff to meet people's needs.
We found that staff had not followed polices and protocols regarding the management of medication which did not demonstrate that the service was effective.
We have asked the provider to tell us what they are going to do to meet the regulations to ensure that the service is effective.
Is the service caring?
We determined that staff showed people respect and promoted their dignity. We saw that staff showed patience when supporting people.
All of the people and their relatives we spoke with were very complimentary about the staff. They described them as being, 'Caring', and 'Kind'. One person who lived there said, 'The staff are friendly and kind'. A relative told us, 'I feel welcome when I visit. The staff are pleasant'.
We found that the provider had adequate processes and systems in place to meet regulations to ensure that the service was caring.
Is the service responsive?
People who lived there and their relatives had been given the opportunity to complete satisfaction surveys. As a result some changes had been made. This showed that the provider was willing to listen to the views of the people who lived there, and their relatives, to improve the overall service provision.
We found that the provider had taken note of the findings from our previous inspection and had taken action to address issues to improve for example, meal choices and the activities provided.
We found that the provider had processes and systems in place to meet the regulations to ensure that the service was responsive.
Is the service well-led?
Prior to our inspection and to the registered manager taking leave we had not identified, or been made aware of any concerns, about Churchfield Court. However, during this inspection we found non-compliance in a number of areas that placed people at risk. (Non-compliance is when we find that the provider is not meeting the law or staff practice or processes are not adequate). We were told by the assistant manager that some of the non-compliance was due to staff not doing what they should. Which showed that the service was not well led.
We have asked the provider to tell us what they are going to do to meet the regulations to ensure that the service is well led.