Church Farm Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We noted the service had addressed and actioned a lot of the concerns following our previous assessment. However, we were not assured over the level of oversight the provider had, due to additional concerns we had identified throughout our assessment that they were not aware of. We felt this was due to a lack of robust processes and the processes that were in place, were not embedded within the environment. However, staff expressed there was a clear shared direction and culture and felt very supported by the registered manager and deputy manager.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Speaking to the staff they all expressed how the service had improved over the last few months, and they felt they were supported by management and their voices were heard.

The service had meetings with staff, and it evidenced that staff were involved in the discussions. They had an improvement plan in place, and they discussed areas with staff and families that they were working on and plans for the future.

Everyone we spoke with expressed how supportive the deputy manager and service manager were. If there were any concerns and support was needed, they were always a phone call away and would come in day or night depending on the support required. They expressed they were always thanked, and this made them feel valued and went a long way. They stated that they took the time to teach them things and explains things if staff needed that support. The managers own competency is carried out to ensure they are capable to assess staff skills within the service.

The service manager had appropriate qualifications in place for their role. All concerns we had identified with the registered manager, and they have been proactive in implementing actions to address them. The Manager appeared knowledgeable in their role and were able to support the staff effectively however we were not assured all processes were fully embedded and because of this that the service had appropriate oversight to identify and drive improvement within the service.

All staff we spoke with felt their voices were heard and could easily raise issues or ideas and they always received a response as to whether that can be implemented or if not, why they can’t. All staff informed us if they raised concerns and they were not happy that it had been dealt with appropriately, they knew the escalation process within the service.

We reviewed the services policies and procedures around freedom to speak up and it was missing important information from it. Where it should record the Freedom to speak up guardian for the service, this area and their contact details were left blank. This is not effective for new staff coming into the service.

All the staff we spoke with expressed that they were given the opportunity to develop and work on their personal development. They said the service were supportive on their career paths and some had flexible working arrangements.

The service had an employee of the month scheme, and this made staff feel valued and supported. Staff were taught by management to upskill their knowledge and staff felt this was done at their pace and they received appropriate support. There were relevant policies and procedures in place around equality, divertisty and inclusion for staff to follow.

The registered manager told us how they implemented the sickness policy as there was an ongoing issue but had since been resolved. They explained how they ensure staff review and assess the needs of people on a regular basis to ensure their care needs are accurate and up to date. However, we noted inconsistencies in the care records which evidenced they were not being updated fully on a regular basis and the management team had failed to identify these discrepancies, we discussed this with the provider in a feedback meeting and they have plans to action this.

The service had a business continuity plan which had outstanding actions with a completion date 2 months prior to when it was reviewed by our inspection team. It had incorrect contact details in them for the staff to follow – Local safeguarding number was the local church instead. The service had a dependency tool in place that helped them analyse the needs of people in the service to ensure they had adequate staffing levels to meet them, however there was an error in some of the formulations, so it was not giving an accurate figure of the amount of hours required. This was not picked up by anyone. We noted poor quality in the care plans, and these had not been picked up on by the services own internal audits.

People we spoke with expressed how the staff supported them to reach out to the local community. 1 individual likes to access the local coffee shop

Speaking to the registered manager, they told us about the service having a wishing tree for people to request wishes that they can try and support to come true, from this they were arranging a few days out next year to meet some peoples requests. They also discussed about the different types of activities that they arrange for the service which involved people coming into the home from the local community.

The people we spoke with felt there was a good working relationship and all worked together to have a positive outcome for people within the service

The service couldn’t evidence any shared learnings or practices between the different partnerships. Although the registered manager had requested for the community nurses to undertake some stoma and catheter training on the staff following our assessment.

All the staff we spoke with noted how much the service had improved in the last few months. However, we identified areas of improvement throughout our assessment and while the service was proactive and implementing measures. They failed to identify these concerns and areas of improvement themselves.

On reviewing the services processes they hadn’t appropriately trained staff to ensure they could meet individual needs. They had not identified a shortfall in staff's knowledge around MCA and DOLs. There were errors identified in their own processes that were not picked up on.