31 July 2019
During a routine inspection
Churchview Care Home is a residential care home spread over two floors. The service provided personal and nursing care to 23 older people, younger adults, and people living with dementia and sensory impairment. The service can support up to 30 people.
People’s experience of using this service and what we found
Systems and processes including governance systems, failed to identify and assess all risks to the health, safety and/or welfare of people who use the service.
For example, certified safety checks had not been completed following the supplier’s guidance and additional monthly checks required further information to assure continued safe use and operation of bed rails to mitigate known risks.
People received support with their medicines as assessed. However, staff had failed to follow policy guidance to ensure medicines prescribe as creams or patches were safely administered with appropriate associated records implemented and maintained. Monthly audits were completed but daily checks failed to implement corrective actions within reasonable timescales to mitigate known risks.
Staff received induction, training and support to carry out their duties. However, there was no evidence of a formal process in place for ongoing or periodic reviews to record where staff were assessed for their competency. For example, to manage and administer peoples medicine. Checks failed to ensure records of supervisions captured how staff were supported in their role and to meet their aspirations.
People’s needs were assessed as required to maintain compliance with the Mental Capacity Act 2005. Some risk assessments and support plans required implementation and updating. For example, where it was agreed to restrict access outside of the home.
People were supported with their health and wellbeing. Records included evidence of involvement from health professionals. This included input from GP’s, occupational therapists, physiotherapists and psychiatrists.
Staff understood how to keep people safe from abuse. People were supported to remain involved with any religious preferences and staff confirmed supporting any diverse needs and treating people equally was embedded into their roles.
People spoke with enthusiasm about the meal time arrangements and the quality of food and support they received. Where people had any dietary requirements, these were supported, and people were monitored to ensure they achieved positive outcomes.
The provider ensured people were supported to enjoy meaningful activities. These included regular trips out, daily events, shows and where people choose to remain in their rooms, daily support and interaction tor remain free from social isolation.
Staff were caring. They understood how to empathise with people who showed signs of confusion due to their dementia. Staff were patient and treated people with dignity and respect.
The registered manager and the provider were passionate about providing a safe service that was based around the needs of the individual person. They were responsive to the concerns we raised during the inspection. Where appropriate some actions were implemented immediately to maintain people’s safety. Other actions were planned for implementation on an action plan to determine the required improvements.
People and their relatives told us they were able to contribute their feedback to maintain and improve standards of care and support. They told us they were confident if they had any complaints the registered manager would address them appropriately.
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 this service was Good (published 30 January 2017).
Why we inspected
This was a planned inspection based on the previous rating.
Enforcement
We have identified a breach of Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because where quality and safety concerns were found during the inspection associated governance did not ensure all corrective actions were implemented without unnecessary delay. This placed people at risk of harm.
Please see the action we have told the provider to take at the end of this report.
Follow up
We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.