Church Farm Care Home

Church Farm Care Home is a residential care home providing personal care and support to up to 40 people. The service provides support to people aged 65 years and over, many of the people were living with dementia. At the time of our inspection there were 36 people using the service. Care is provided across 2 floors, with communal spaces including bathrooms and lounge areas, there is a people carrying lift in place.

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

People were not living in a well maintained care environment, with many surfaces and items of furniture damaged, impacting on the ability of staff to keep them clean. People were not being supported by sufficient numbers of suitably trained staff, particularly at night time, increasing the risks relating to the ability of staff to meet people’s assessed needs, including in the event of an emergency such as a fire.

The oversight and management of people’s individual risks in relation to their pressure care, food and fluid intake, falls management, diabetes care, mental health and wellbeing and bowel monitoring was all found to be poor. People were at risk of accessing items such as denture cleaning tablets, drink thickening powder and personal care products including razors, without staff supervision. This was of particular risk for those people living with dementia who were reliant on staff to maintain their safety.

People were not receiving their medicines safely, with poor oversight of medicines management by the registered manager and provider. The quality of audits and checks in place to provide high standards of care were ineffective. Where the provider’s own audits had identified action needing to be taken, we found these were not addressed in a timely way to maintain people’s safety.

Where people were involved in accidents and incidents this information had not been consistently reported to CQC in line with the registered manager and provider’s regulatory responsibilities. Overall, the registered manager and provider did not have oversight of what accidents and incidents were happening at the service, due to a lack of reporting systems in use.

People were not always 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 service offered limited activities, did not foster inclusion for many of the people seated in the main communal lounge, and did not offer the standard of meaningful activities outlined in the provider’s own statement of purpose.

People’s levels of privacy and dignity were not upheld, for example when transferring people using equipment in communal areas of the service, or where people were receiving personal care in their bedrooms. People’s continence products were left in large boxes in corridors, next to fire escapes and on show in people’s bedrooms, impacting on their privacy and dignity. People were observed to repeatedly ask staff for support to access the toilet and staff did not return in a timely way to meet their needs.

The service was not well led, and the new provider had not completed detailed audits and checks on taking over the ownership and accountability for the service. There were risks relating to closed cultures within the service, with staff morale found to be low, and many staff tearful when speaking with us.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The service was registered with us on 14 July 2023 and this is the first inspection under a new registered provider. The last rating for this service under the previous provider was requires improvement (published 18 December 2019).

Why we inspected

The inspection was prompted in part due to concerns received about safe staffing levels, responsiveness of care and food quality. A decision was made for us to inspect and examine those risks.

Enforcement and recommendations

We have identified breaches in relation to safe care and treatment, provision of dignified care, the assessment and implementation of the Mental Capacity Act (2005), meeting people’s nutritional and hydration needs, good governance and oversight of the service, and staffing levels.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow Up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.