Church Farm Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

The learning culture and safe systems and pathways had improved since we last inspected the service. The service safeguarding processes were effective, however we identified concerns around staff’s knowledge of Deprivation of liberty safeguards and we were not assured that processes were not effective to manage risks of people’s needs within the service. There were some concerns in the environments risk assessments and vacant rooms were not locked consistently and could pose a risk to people with dementia. There were sufficient staff to meet the needs of people within the service however we were concerned that staff did not always have adequate training to meet individual specific health needs. We addressed this with the service, and they are working on improving this. The environment was visibly clean although we were not assured there were robust Infection Prevention Control measures in place to identify concerns. We noted there were concerns over the medication competencies carried out on staff however these were resolved throughout our assessment and no additional concerns were identified over the management of medications.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

All the people we spoke to living in the service knew who to raise concerns too and felt confident in doing so. Relatives we spoke with expressed that they were not aware of the policy but if they had any concerns they would speak to the manager or the deputy manager. While we carried out our assessment, we observed an individual raising concerns in the service and this was being handed over between different shifts to address the issue.

The staff we spoke with all expressed that safety concerns were looked into. They felt management investigated situations appropriately and updated staff on different learnings and new ways of working when they arise. Additional training was undertaken following incidents. The manager confirmed they were signed up to the Central Alerting System (CAS) which notified the service of safety incidents. While undertaking our assessment we identified concerns around the staff training and we brought this to the managers attention. We acknowledge that actions were implemented following concerns that were identified with the staffs training but they were not the most effective or sustainable as requesting district nurses to come in and complete the training did not cover areas of assessing assessors, to ensure they were competent in assessing other staffs competency. It did not cover new care staff coming into the service. They would have to wait a considerable time to have this training carried out. Additionally with concerns around the fire audits, risks were overlooked as staff continued to be unaware over repeated months of where the fire box was and this was not identified as a wider learning need within the service.

We reviewed the services complaints process and they were able to evidence complaints they had received and the action they had taken from it and any lessons learnt that had been identified. The service received CAS alerts which is a good process however we could not evidence that they had reviewed them and any action they had taken.

People in the service and relatives all expressed the responsiveness of being able to see a GP or nurse when there is a concern over their health. They felt staff put referrals through in a timely manner and the Local GP surgery comes into the service once a week and carries out ward rounds. The service request who they would like to be seen and add people on to the list if it is needed.

They used an electronic care recording system that held all the care plans, daily notes and risk assessments of people living in the service. The staff reviewed this daily to see what healthcare professionals were due into the service that day and they could chase up visits where required. Speaking to staff they informed us of reflective accounts on situations when they had to raise concerns with healthcare professionals about an individual’s health and how they were presenting and had requested full assessments to be carried out. The staff also informed us of the importance of ensuring correct documentation was always taken with individuals when being transferred between services.

We spoke to an individual from the local community district nursing team who felt the service responded when there were concerns of someone under their care and they were always referred promptly. The nurses visited the service daily and felt they were good at following advice.

Referrals were submitted in a timely manner and this was confirmed through speaking to the community district nurses and people living in the service who stated they saw healthcare professionals regularly.

All of the people we spoke to in the service felt and safe and relatives we spoke with felt their loved ones were safe also. They knew how to raise concerns and felt empowered to do so and staff responded appropriately to concerns raised.

We spoke to staff in the service about their knowledge of safeguarding people and they could inform us the appropriate process they must take if they were concerned around an allegation of abuse. However, we spoke to staff about the mental capacity act (MCA) and deprivation of liberty safeguards (DOLS) and staff did not know what DOLS was and what it entailed. This concerned us when people were being deprived of their liberty within the service and staff were not aware.

We observed staff being very polite in how they spoke to people in the service, allowing people to take their time and support them. There appeared to be a big improvement on staff culture and people working together to support people within the service. 1 individual with dementia could walk freely around the service. The environment was clear of hazards in corridors and issues were addressed quickly when we notified the service. However vacant rooms were not always locked and had a lot of materials in that could cause a hazard in, when we notified the service, this was dealt with apart from 1 room on the first floor, due to it being an escape route, although there was a risk assessment in place for this, we were not assured on its effectiveness.

We reviewed the services safeguarding records, and they appeared to be clear and evidenced all concerns were escalated to the Local Authority and CQC in a timely manner and recorded outcomes when they were received. We reviewed the services DOLS records and there was one with an outstanding condition that had not been actioned by the service. There was DOLS that were applied for and the service had escalated these on a monthly basis when there had been no follow up, some were applied for back in May 2023.

People expressed they were listened too when it came to their care needs and were supported how they wanted to be supported. People that required to be weighed weekly due to risk of malnutrition were and people were on supplements where there was a known risk. People were supported with appropriate equipment to aid their mobility where it was needed.

Staff spoke about how they have a responsibility to ensure the environment Is tidy and free from hazards, how they ensure they check equipment Is safe to use and making sure people have access to aids to support them, Rollator Frame or call bell to hand. Staff expressed how they make people in the service aware of risks but also respect their independence and decisions if they have capacity.

We observed the environment and interaction between staff and people within the service. Staff supported people appropriately and guided and prompted them when it was needed. We observed people had their call bells within reach and people also wore pendant alarms and this made them feel safe.

We reviewed a selection of care plans and risk assessments within the service, and we found they were inaccurate and had contradicting information in them. Risk assessments were duplicated and had different scores in them and were not always a true reflection of people’s needs. 1 person who used emollient creams that had paraffin in it, which is a source of ignition; was not reflected in the individual’s Personal emergency evacuation plan which discusses the risk of fires. This meant the risk assessment was not a true reflection of the risks posed.

All of the people with spoke with and the relatives felt the environment was safe and they had noted an improvement within the service.

When we arrived on site we were asked to sign in and asked for out Identification. Call bells were answered very promptly throughout the day. We discussed concerns with the registered manager around vacant rooms being unlocked and we were not assured of the measures initially taken. Being checked 3 x times a week was insufficient and didn’t cover weekends or out of hours. However, the manager has now implemented measures to ensure it is checked twice daily by staff.

On our onsite assessment we noted a radiator covering came away from the wall in the lounge, we addressed this with the manager and as soon as the maintenance arrived it was fixed immediately. There was adequate signage throughout the home when there was a change in floor level. There were some vacant rooms that were being decorated. However, we noted some of them were unlocked and they had items in the room that could be a hazard to people with dementia. There was a bookshelf in the lounge that was connected to the wall by a cable tie and hook however it was able to move when pushed, so, although the bookshelf wouldn’t topple forward, items on the bookshelf could and could land on an individual. We reviewed fire equipment visibly and checked they were all in date and serviced. All the corridors were kept clear. DSE assessments were only carried out on manager and deputy when all staff use an electronical device to record their daily notes and review and update care plans, we brought this to the managers attention on feedback on the day.

All maintenance paperwork was reviewed. Where equipment had failed it had been removed and either fixed appropriately or replaced due to being the most economically effective solution. All required services were carried out within the environment and additional items were serviced to ensure they were checked on a regular basis. We found not all risks assessments were dated or signed so unclear how up to date they were and how embedded they were within the service. The lift risk assessment didn’t cover the risk of people with dementia accessing it. There were monthly audits on the fire grab bag completed and consistently each month staff were not aware of how to access the fire box. 1 staff member was asked twice over 2 months and was still not aware on the second time. The service failed to note this was a pattern of staff’s uncertainty and implement an action to address this with all staff which did not assure us on how the service would respond in the event of a fire. Additionally, the service could not evidence that all staff had completed a fire drill within the last year. They were completing regular drills but had no log to register the staff and note when they last attended a drill.

the people we spoke with had noted there had been a change of staff over the last few months. However, they did not have to wait long for their call bells to be answered. They knew the staff well and knew who the manager and deputy manager were and felt they could speak to them.

All the staff we spoke with felt there was an adequate number of staff on shift. They expressed if there was sickness, they had support from management within the home and if they generally needed help, they were always there to get involved and support the team. We noted staff had not always been given adequate training to meet people’s needs in the service. There were people living in the service who required support with specific health needs and staff had not received adequate training to enable them to do this, We brought this to the managers attention and they had planned to address this issue with sourcing training and carrying out competency checks on the staff however their plan did not cover the competency of the assessor carrying out those checks.

We arrived early hours due to previous concerns of staffing levels at night and we found adequate staffing levels. We observed staff handovers between shifts and they clearly communicated how people in the service had been and they noted any significant concerns that staff needed to be aware of and communicated what has been addressed. There were staff around throughout the day and it was noted call bells were answered promptly.

We reviewed 4 HR Records, and everything was completed to ensure safe recruitment checks were carried out prior to people starting their employment. We noted in the services improvement plan Supervisions were an area on improvement however there were gaps in the supervisions records and 7 staff were due to have their supervision completed in August 24 and these were not completed and had not been carried forward into the following months to complete. Within the improvement plan it was noted the importance of regular supervisions with staff to maintain the staff morale as this was previously low, so it is important that these supervisions were carried out. The supervision policy states 4 supervisions per annum. By October some staff had only had 1 supervision that year. Appraisals were incomplete also, however they were planned for the remainder of the year.

Everyone we spoke with was happy with the cleanliness of the environment and theirs rooms. 1 person we spoke with said “Every month they do a deep clean and move everything and clean. But always light cleaned every day.”

The staff said the environment was being refurbished on a schedule and this has aided them into cleaning the rooms that had been refurbished to a higher standard and made the process easier for them and achievable.

The environment was clean to a good standard when we were onsite. We observed the domestic team going around with their trolley and equipment. They had colour coded buckets that were being used throughout the service and The kitchen had it owns cleaning schedule that was being followed. The kitchen was recently refurbished.

We observed cleaning schedules in place and environment was visibly clean. initially, we were not assured the service was carrying out Infection prevention control (IPC) audits that cover the whole service and the staff's handling of IPC including hand washing. However following our assessment the service provided us with this documentation to evidence this was being carried out appropriately.

We spoke to people in the service and they were involved in medication reviews and could manage their own medication if they wanted but they preferred the service to do this as it was one less thing for them to worry about. Some people that required support to manage their medications had mental capacity assessments in place to support them.

Staff could tell us what medicines people were on and why. The leaders within the service showed a significant improvement with the management of medication and that there had been no errors within the service since January 2024. Medicines were stored safely and at correct temperatures. Records showed that people received their oral medicines as prescribed. Staff carried out regular checks of medicines and records to ensure this. However, we noted some gaps in records for the application of people’s topical medicines.

On the first onsite assessment medication competencies had no review dates and some were missing outcomes of the competency, so it was not clear if the staff member was competent or not, however a medicine inspector attended the service following our initial visit and confirmed this was resolved. Written information was available for staff to refer to about people’s medicines including guidance on how they have their medicines given to them and for medicines prescribed on a when required basis (PRN). This is to ensure staff gave them to people consistently and appropriately. We noted that the PRN protocols were not dated, or their planned dates of review indicated, however, the manager assured us the protocols had recently been reviewed. Staff authorised to give people their medicines had been assessed as competent when giving people their medicines. The service had identified medicines risks and put in place appropriate risk assessments.