About the service: Church House is a care home for up to 44 people. The service provides nursing care for frail older people. During the inspection 23 people were being supported by the service.

People's experience of using this service:

Since the previous inspection the registered provider had worked to address the issues identified and improve the quality of the care. A temporary manager had been employed and along with the regional manager and quality team, had made improvements. This manager recently left the organisation and a new manager has commenced at the home. The new leadership team were keen to make ongoing, consistent improvements and to create a stable staff team.

Overall, people and relatives were positive about the care and support they received. Staff felt happier that a permanent management team were in place and felt the home was more organised. Effective systems were now being followed to check on the quality and safety of the service and improvements were made when required. These improvements need to be consistent and sustained.

Staffing was kept under review. Overall there were enough staff to meet people’s needs, however some people raised concerns about changes in staffing. The new manager was making further improvements to the way staff were organised.

We found that medicines were managed safely and audits had effectively identified where improvements were required. Risks were identified and appropriate action had been taken to reduce these risks.

The building and equipment were clean and safely maintained. Some decoration and environmental improvements were being made.

People were satisfied with the food and drink available. Any nutritional risks were monitored and acted upon. There remained some gaps in the completion of records to monitor the care and support provided. The management team were aware of this and had been supporting staff to address this.

People told us staff were kind and caring. We received some very positive feedback about the compassionate support they had received at Church House. Ongoing improvements were needed to embed a person-centred approach.

Improvements had been made to care plans, however we found further improvements were required to ensure they included all specific details and that all charts were fully completed.

Staff were knowledgeable about people’s individual needs and responded well to any changes required.

People felt able to raise any concerns and knew how to make a complaint if necessary.

Quality assurance systems were in place and were being used more effectively to monitor key aspects of the service. Audits and checks were completed on a regular basis by the management team and registered provider to identify areas of improvement. A detailed home improvement plan had been implemented and the new manager continued to act on the necessary improvements.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

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

Rating at last inspection: Inadequate (Published 16 October 2018).

Why we inspected: This was a planned inspection based on the rating at the last inspection. The service had improved from inadequate to requires improvement overall.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received, we may inspect sooner.

This comprehensive inspection took place on 21 and 23 August 2018 and was unannounced.

During our last comprehensive inspection in July 2017, we found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This related to person centred care, need for consent, safe care and treatment and governance.

Following the last inspection, we asked the provider to complete an action plan and we also met with the management team. This was to confirm what they would do and by when, to improve the key questions of safe, effective, responsive and well-led to at least a rating of good.

Church House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Church House accommodates 44 people in one adapted building. The accommodation is based over two floors. At the time of our inspection there were 32 people living at the home.

At this inspection in August 2018 we identified continued breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 with regards to Regulation 12 (Safe care and treatment), Regulation 17 (Good governance) and Regulation 9 (Person centred Care)). One new breach was found relating to Regulation 18 (staffing). The provider was no longer in breach of Regulation 11 (consent).

We found the service 'Inadequate' and the service is therefore in 'special measures.'

There was no registered manager in post at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. An interim manager had been in post since the departure of the previous registered manager in April 2018 but had subsequently resigned. A new home manager was about to start at the service and we were advised they would be applying to register as the manager.

Risks to people's health and safety were not always suitably assessed and managed. Timely action had not been taken to act on recommendations made by health professionals.

There was not always enough staff deployed to meet people’s needs in a safe and timely way. Feedback demonstrated that people and relatives were concerned about staffing levels and changes to the staff team. The recruitment of staff was a priority and we saw that staff were recruited using safe procedures.

Suitable arrangements were in place for the safe administration of medicines.

Safety checks were carried out on the premises. Following our inspection, the local fire service undertook a fire safety audit of the home and we were advised that some actions needed to be carried out within certain timescales.

Records did not demonstrate that staff were trained to provide safe and effective care. Staff had received some supervision meetings with managers, however the provider could not evidence the frequency of these.

People had choices of food and drinks, they were complimentary about the food on offer. However, people's nutritional risks were not always managed safely.

Improvements had been made to ensure compliance with the MCA. Staff sought consent before providing care to people.

People’s bedrooms were decorated and personalised according to their preferences.

There were some members of staff who had worked at the service for some time and had good knowledge of people’s backgrounds and preferences. Where possible staff supported people to be as independent as they wanted to be.

People told us that staff treated in a kind and caring manner, respecting their dignity. However, the service did not always give the staff the time they needed to provide care in a caring and p

This inspection took place on the 5 and 11 July 2017 and was unannounced. We previously carried out an unannounced inspection at this home on 11 and 12 August 2016, where we identified shortfalls to the care provision and we identified breaches in number of areas. Following that inspection, we asked the provider to take action to make improvements and we served two warning notices.

At this inspection we found that some improvements had been made in certain areas but sufficient improvements had not been made in all areas. We found that the registered provider was no longer in breach of Regulations relating to safe recruitment, staffing and the safe management of medicines. However they remained in breach of Regulations relating to good governance, consent to care and person centred care. We identified a further breach relating to the safe management of risk.

Church House Care Home is a 44-bed nursing home situated about a mile from Nantwich town centre. The home has a conservatory, quiet sitting areas and a large lounge area which looks out on to the front garden and car park. It has off road car parking facilities available. On the day of our inspection there were 31 people living in the home.

A new manager had recently been appointed and they were not yet registered with the Care Quality Commission. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Overall people spoken with were complimentary about the care they received at Church House.

We saw that risk assessments had been undertaken in a number of areas including moving and handling, falls, pressure ulcers and choking amongst others. We also observed that staff used specialist equipment to move people safely and saw that action was taken to manage the risk of people developing pressure ulcers. However, we found some examples where risk assessments had identified actions to reduce the risk but staff had not always ensured that these were followed.

At this inspection we checked whether staff understood how to protect people from harm or abuse. Staff spoken with were aware of safeguarding procedures and were able to tell us what to report and how they would report concerns of this nature. We found some shortfalls regarding the safety of the premises specifically relating to fire safety and referred these issues to the local fire service. We subsequently received information to inform us that these issues were being addressed

We found that improvements had been made to staffing levels and there were sufficient staff to meet people’s needs in a timely manner. We found that improvements had been made to the management of medicines. A new electronic medication management system had been introduced.

At this inspection we found that the service was still not always working within the principles of the MCA and DoLS. Whilst overall people told us that staff sought their consent to provide care, we found one example where staff had not respected a person’s wishes regarding their care. The home manager had identified that further training was required in this area.

Staff had received an induction and some training. However this was an area that the manager was focused on making further improvements. A training programme had been implemented and plan has been made to provide all staff with regular supervision.

People we spoke with told us that the food was good. We observed the meal being served at lunchtime, which looked appetising. Pictorial menus were on display in the dining room and choices were available. We saw from the care records that people's nutritional and hydration needs were recorded, there was evidence that staff were monitoring people who were at risk of losing weight.

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This unannounced inspection took place on 11 and 12 August 2016.

We previously carried out an unannounced inspection at this home on 10 March 2015, where we identified shortfalls in the standard of care. These included shortfalls in the induction of new staff and the on-going training and supervision of staff members employed. We found that the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards were not being followed and there were not always enough staff in the home to meet everyone’s needs. Following this inspection, we asked the provider to take action to make improvements.

We undertook this inspection to check that they had followed their plan and to confirm that they now met legal requirements. We found that the provider had not made sufficient improvements and remained in breach of the legal requirements. We also found a further three breaches of the relevant legislation.

Church House is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. At the time of our inspection visit there was a home manager who had not yet been registered with the Care Quality Commission. The manager had submitted an application, but was unaware that the application had been returned for further information. We received information following the inspection to confirm that the manager had re-applied to register. The regional manager and a manager from another of Akari’s services were present during the inspection visit.

Church House Care Home is a 44-bed nursing home situated about a mile from Nantwich town centre. The home has a conservatory, quiet sitting areas and a large lounge area which looks out on to the front garden and car park. It has off road car parking facilities available. On the day of our inspection there were 32 people living in the home.

People told us that they felt safe living at Church House. However, we found that sufficient staff were not always deployed, to meet people’s needs in a timely manner. People told us and we observed that people were kept waiting for support at busy times, especially during the morning. Agency staff had been used to cover where there were staff shortages and the manager was focusing on the recruitment of new staff.

There were shortfalls in the way that medicines were administered. We found that there was a lack of clarity about the process for recording the administration of creams onto the MARs and we were not able to see from the records whether these products had been used correctly. There were also issues with the administration of covert medication.

We saw that some recruitment checks had been made, but we could not always evidence that recruitment procedures were robustly followed and that applicants were checked for their suitability, skills and experience. Staff spoken with understood what safeguarding was and knew how to report any concerns within the organisation.

We found that the home was clean, well decorated and maintained. The maintenance person ensured that all appropriate checks were carried out and recorded.

Staff told us that they received suitable training, although records were not available at the time of the inspection to evidence individual staff training details. The manager told us that the induction of staff was an area that needed to be developed and the provider was devising a new induction programme in line with the Care Certificate. Some staff had received supervision but these had not been carried out consistently in line with the provider’s policy.

We found the provider had not made sufficient improvements to ensure they acted in accordance with the requirements of the Mental Capacity Act (MCA). We saw that some a

The inspection was unannounced and took place on the 10 March 2015.

Church House is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. At the time of our inspection visit the home manager who had not yet been registered with the Care Quality Commission was not working in the home. Following this inspection we were informed that the manager had now left the home and the registered provider was appointing a new manager.

The regional manager and a registered manager from another of Akari’s services were present during the inspection visit.

Church House Care Home is a 44-bed nursing home situated about a mile from Nantwich town centre. The home has a conservatory, quiet sitting areas and a large lounge area which looks out on to the front garden and car park. It has off road car parking facilities available.

On the day of our inspection there were 38 people living in the home.

We spoke with a number of people living at the home. The overall feedback was that there were not always enough staff in the home to meet everyones’ needs. We heard of examples where people had requested help but been left waiting for some time. We had concerns that people at risk of falling were not able to access help from staff in a timely way. Staff told us they did not always feel they could provide anything more than basic care and had little time to spend with people to enhance the quality of their life.

This is a breach of Regulation 22 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 which corresponds to Regulation 18 [1] of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Whilst people expressed concern regarding staffing levels we did observe during our visit that there were relaxed and friendly relationships between the people living in Church House and the staff members working there.

We identified shortfalls in the induction of new staff and the on-going training and supervision of staff members employed.

This is a breach of regulations 22 and 23 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which corresponds to Regulation 18 [2] of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Although the service had a range of policies and procedures regarding the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards we found that these were not being followed.

We looked at six care records in detail. We saw in all files, Do Not Attempt Resuscitation Forms (DNAR). These were signed by the GP; however the DNARs were not accompanied by supporting evidence such as completed mental capacity assessments or records of Best Interest Meetings.

This is a breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 which corresponds to regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The service had a safeguarding procedure in place. This was designed to ensure that any possible problems that arose were dealt with openly and people were protected from possible harm. Staff members told us they understood the process they would follow if a safeguarding incident occurred. This indicated that they were aware of their roles and responsibilities regarding the protection of vulnerable adults and the need to accurately record and report potential incidents of abuse.

We looked at the files for the recently appointed staff members to check that effective recruitment procedures had been completed. We found that the appropriate checks had been made to ensure that they were suitable to work with vulnerable adults.

A tour of the premises was undertaken; this included all communal areas including lounge and dining areas plus and with consent a number of bedrooms. The home was well maintained and provided an environment that could meet the needs of the people that were living there. The home had recently undergone a refurbishment. This included redecoration, new furniture, carpets, curtains, new beds and wardrobes.

The home had a complaints policy and processes were in place to record any complaints received and to ensure that these would be addressed within the timescales given in the policy.

Meetings for the people using the service and their families were taking place and we saw that the most recent meeting had been held on the 27 February 2015.

When we inspected Church House Care Home in November 2013 we found that that staff were not at all times provided in sufficient numbers. The provider was not able to consistently respond to unexpected changes in circumstances in the service. The provider was not always able to provide staff in the event of short notice absenteeism by care staff.

This inspection was undertaken to check that the provider had delivered the actions it undertook to carry out in order to ensure that people using services were always cared for and supported by sufficient numbers of staff having suitable skills for their caring role.

We found that improvements had been made to the provision of staff on duty and mechanisms to respond to staff absence had been strengthened. Staff were clear about their duties. Duty rotas were prepared well in advance.

One person living in the home said "I'm very happy here. All of the staff are excellent and I feel safe and treated with respect. I'm not kept waiting and staff listen to me".

This was a scheduled inspection brought forward due to concerns had been raised about possible low staffing levels in the home.

During the inspection we found that there were sufficient staff on duty. The provider used assessment and planning tools such as dependency scoring to determine what staffing levels were required. Staffing numbers provided were on the basis of the numbers of people living at the home and the complexity of their needs. We saw records which demonstrated that occasions staffing had fallen below the providers own planned rota. One staff member said, “Yes, there are enough staff; that's if people don't phone in sick at the last minute". Another said "care staff can be very stretched". Care records showed that people living in the home had not been disadvantaged or in receipt of poor care because staffing numbers had on occasion fallen below the required levels on occasions. However, there was a risk that people’s needs would not be met unless robust systems were in place to address the concerns in this area.

In this inspection we looked at other aspects of the service. The home was clean and good infection control practices were observed. We found that people’s nutritional needs were well assessed and that good wholesome food was provided and that choices were available. We saw good evidence that consent to care and treatment was properly obtained and that the care given was delivered in a way that was intended to ensure people's safety and welfare.

The inspection visit was carried out to check if improvements had been made following the previous review of compliance 12 November 2012. At the time of our visit there were 26 people who lived at Church House Care Home. During the course of the inspection we spoke with eight people who used the service and a family member. We found that improvements had been made to ensure that people received appropriate care in line with their assessed needs.

One person told us: “I’ve not noticed much change other than a few new faces but I’ve always found the staff to be okay.”

We saw that care plan details and fluid and hydration documentation had improved. We saw clear monitoring of people’s weights and that staff reported any change in people's appetite appropriately.

The Manager told us the home would be refurbished in the first wave of improvement plans from the provider Akari Care Limited and the refurbishments would commence in February 2013. Areas of refurbishment included general décor such as carpet replacements, equipment such as some new profiling beds, improvements to bathroom and laundry areas, sluice, garden pavements and new furniture. The Fire and Rescue service had revisited the home and were satisfied with the actions taken by the service to address fire drills and training.

Staff told us that there were sufficient permanent staff on duty to meet people’s needs appropriately and people we spoke with raised no concerns about their care.

We spoke with three people about medicines handling at the home. Everyone we spoke with was happy with the arrangements in place when nurses and care workers administered their medicines. One person told us, “You don’t have to worry”. A second person confirmed that they were “not in pain” and could have their painkilling cream if they needed it.

The majority of the people we spoke with made positive comments about the care provided at the home. One person using the service told us: “The staff are very approachable.” Another person said they were, “sometimes” well looked after.

We spoke with a regular visitor to the home who told us: “The staff are very approachable". A relative told us that they had no concerns over the standard of care their family member received.

We spoke with five people about medicines handling at the home. Everyone we spoke with was happy with the arrangements in place when nurses and care workers administered their medicines. However, as identified by the manager in their medicines audits, we found that the home’s medicine policies were not consistently adhered to. And, there were occasions where people missed doses of medication because there were none left in stock to give, putting their health and wellbeing at risk.

We found that there were areas where improvements were needed. These included care plan and risk assessment documentation; contingency planning for staff sickness/absence levels so they do not impact on the people who used the service: staff training and fire safety checks. We did see that the manager and regional manager had devised an action plan to address some of the issues raised following their own audits, however some of the areas of concern were raised during the previous inspection and had not been adequately addressed.

For the purpose of report writing it was important to note that Church House Care Home had a change in provider in October 2011. The new provider Bondcare Nilerace Limited had inherited an older building with refurbishment and investment needs. The manager had recently been appointed and had taken the manager role in March 2012 and was to apply to the Care Quality Commission to become the registered manager.

We visited Church House Care Home unannounced and spoke to several people about the care and support they received as well as speaking with a number of relatives and visitors to the service.

People told us they had some choice in what they do and when they do things. One person told us: "They ask me what I want to eat and where I would like my tea." Another person told us: "I prefer to sit in the lounge after breakfast and watch television with another lady, the staff know about my preferences and help me to get to the lounge." However one person told us they had hoped to be introduced to the manager as a courtesy but felt that that this had not happened, although they had no concerns to raise.

One person told us: “The staff are great, X, is so lovely, kind and gentle, in fact they (the staff) all help me."

People told us the atmosphere was relaxed in the home and said that people in general got on well with each other.

People using the service said they were regularly asked their opinions about how they were cared for and supported at Church House Care Home and one person said: "I think they had a relatives and resident meeting not very long ago."

We spoke with one person who told us: "They (the staff) know me well and they know what I like to do and I feel happy here."