Church Rose Nursing Home

Updated 9 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.

Inspection team

The inspection team consisted of 2 inspectors and 2 Experts 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 Rose is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Church Rose 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 a registered manager in post.

Notice of inspection

The inspection was unannounced.

What we did before the inspection

We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make.

During the inspection

Inspection activity started on 01 November 2023 and ended on 09 November 2023. We visited the service on 01 November 2023, which was unannounced and returned on 02 November 2023, as agreed in advance with the operations manager. However, at the start of the inspection the registered manager was on holiday, so we visited for a third day on 07 November 2023 to give them the opportunity to show inspectors what they had implemented and improved. This was agreed with by the senior management team. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We spoke with 12 people who used the service and 18 relatives about their experience of the care provided.

We spoke with 16 staff members which included the registered manager, nominated individual, deputy manager, compliance and quality manager, operations manager, director of operations, nurses (days and nights), senior healthcare assistants (days and nights), healthcare assistants (days and nights), home administrator, head chef and cook, housekeeping team and the activity co-ordinator. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We also gained feedback from two health professionals who support people living in the service.

We reviewed a range of documents and records for 12 people, this included care plans, risk assessments, daily notes, and medicine records. We looked at 4 staff recruitment files and training records. We also looked at records, systems and processes related to the management and quality assurance of the service.

After the inspection

We continued to review information which the registered manager and provider shared with us.

Updated 9 December 2023

About the service

Church Rose is a care home, providing personal and nursing care to up to 48 people, in a purpose built building. The service provides support to older and younger adults, people living with dementia and learning disabilities. At the time of our inspection there were 44 people using the service.

People’s experience of the service and what we found:

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence, and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. We considered this guidance as there were people using the service who have a learning disability and or who are autistic.

Right Support

Risks to people were well managed which meant risk of harm to people had been considered .There was evidence to demonstrate people had been supported with things which were important to them such as maintaining contact with family and their hobbies, and staff knew people well. Medicines were well managed.

Repairs and general maintenance were dealt with promptly, which decreased risks to people.

People lived in a purpose built building with a safe outside space which we saw people enjoy. The home was situated in a residential area with facilities close by which people could access. There were adequate numbers of staff to support people.

Right care

People’s care plans and risk assessments reflected their current needs and what was important to them. Staff received appropriate training to meet people’s needs. People were supported and encouraged, promoting their independence.

There was a stable team of staff who knew people's needs and were kind and caring.

Right Culture

The registered manager and other staff members told us how the manager had worked hard to ensure the culture within the service was open and inclusive .

People were not consistently supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

The provider had systems in place to monitor the quality and safety within the service. However, these needed some improvement as they had not highlighted some of the issues we found. For example, concerns about the implementation of authorised conditions for people with Deprivation of Liberty Safeguards (DoLS) and infection control practices. Where the provider’s systems had highlighted concerns, at times there was a delay in completing the required actions.

The provider acted during the inspection to rectify the concerns in relation to authorised DoLS not being actioned.

We observed some infection control concerns such as, lack of evidence that equipment such as hoists had consistently been cleaned after use, staff wearing jewellery and long acrylic nails and clothing items which hung down, tables laid for meals where staff sat for handover, toilet rolls on top of toilet cisterns, un-used continence pads hanging on the dirty linen trollies, aprons hung over handrails. These issues were addressed by the management team at the time of the inspection.

People were supported to maintain links with loved ones. People had access to a variety of in-house activities to engage in, although some people told us these activities were not of interest to them. Although staff knew people well and how to meet their needs, this was not always supported by the daily records completed by staff members following the activity they had been involved in. The information around people's interests in care plans and risk assessments were detailed.

People and relatives knew how to raise concerns and most felt confident any issues would be addressed. However, two relatives told us they had raised concerns, which the registered manager said they would address but felt they had waited a long time before this has been actioned. The registered manager addressed these concerns when brought to their attention.

People were supported by staff who were trained and knowledgeable about how to identity and minimise risks regarding their safety and wellbeing.

Most staff felt supported in their role and described the management team as approachable, caring, and responsive. Some staff however, told us they felt they were not listened to.

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 15 May 2018). At this inspection we found the service required improvement.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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