21 March 2023
During an inspection looking at part of 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.