Church Terrace Nursing Home

Updated 6 December 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 3 inspectors 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

Church Terrace Nursing Home is a 'care home'. People in care homes receive accommodation and nursing and personal care as a single package under one contractual agreement dependent on their registration with us. Church Terrace 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 not a registered manager in post. A new manager had been in post for 4 months and had submitted their application to register. We are currently assessing this application.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 8 people living in the home and 8 relatives about their experience of the care provided. We spoke with 13 members of staff including care workers, team leaders, nurses, deputy manager and the manager. We received feedback from 1 visiting professional.

We reviewed a range of records. This included 5 people's care records and medicine records. We looked at 3 staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service were reviewed, including policies and procedures and health and safety documents.

Updated 6 December 2023

About the service

Church Terrace Nursing Home is a care home providing personal and nursing care to up to 65 people. The home consists of 4 wings, 1 of which is an adapted building separate to the main care home. The service provides support to younger and older adults, some of whom were living with dementia and people with mental health concerns. At the time of our inspection there were 60 people living in the home.

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

Since the last inspection, improvements were found to the overall care and support people received. However, further improvements were identified regarding quality monitoring of equipment, such as mattresses and time was needed to monitor the success of the newly implemented quality monitoring systems.

People and relatives spoke positively about the service they received. Staff knew how to keep people safe and protect them from harm. Risks associated with people’s care and the environment were identified and assessed. People received their medicines safely, when needed, by staff trained in medicine management. Staff were recruited safely.

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.

Staff told us they felt supported by the registered manager and attended regular meetings. Relatives told us they felt included in the service and felt confident to raise concerns.

The provider and staff worked in partnership with other health and social care agencies to deliver good outcomes for people and ensure their needs were met and reviewed. A visiting professional told us the provider followed their recommendations and communicated effectively.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 6 June 2023) and there were breaches of regulation.

At this inspection we found the provider had made significant improvements and was no longer in breach of the regulations found in the previous inspection. However, there were still improvements to be made and time was needed to establish the newly implemented systems.

Why we inspected

We carried out an unannounced focused inspection of this service on 6 June 2023, during this inspection we followed up on the breaches of the previous inspection. However, at the time of our visit, the deadline we set for the provider to be compliant with regulations had not yet passed. Therefore, breaches of legal requirements continued to be in place. The provider had failed to ensure the safe care and treatment of people, to support people to consent to their care and ensure good governance of the service. These failings breached regulation and we issued 3 warning notices.

We undertook this focused inspection to check the provider had made improvements and to confirm they now met legal requirements. This report only covers our findings in relation to the key questions Safe, Effective and Well-led which contain those requirements.

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.

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

Follow up

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