This inspection took place on 13 and 16 November 2018; the first day of inspection was unannounced. We made telephone calls to some staff on 15 November 2018.

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

Churchfield Care Centre accommodates up to 60 people in two separate buildings. At the time of our inspection one building was not in use. There were 22 people with nursing needs and six people with residential needs accommodated in one building that had capacity to accommodate up to 33 people.

At our previous inspection on 17 and 31 July 2017, we found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 for Regulations 10, 12, 17 and 18. These related to people not being treated with dignity and respect, not receiving safe care and treatment, an inadequate deployment of staff and ineffective management of risks and governance. At this inspection we found some improvements had been made and the provider was no longer in breach. However, some improvements were still required and the service is rated as ‘Requires Improvement.’ This is the fourth consecutive time an inspection has rated the service ‘Requires Improvement.’

There was a registered manager in post at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are registered persons. Registered persons have the legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At this inspection, people’s privacy and dignity had not always been respected. Records, including medicines administration records, required improvement. Not all staff received the support of an induction and competency checks before they were responsible for people's care. Improvements were needed in care planning when people approached the end of their lives.

People felt safe and the provider had taken steps to help ensure people were protected from harm and abuse. Staff were trained and knowledgeable on safeguarding procedures. Recruitment checks helped the provider make decisions on the suitability of staff to work at the service. Staff were deployed sufficiently to meet people’s needs in a timely way and maintain checks on people in communal areas and in their rooms.

Arrangements were in place for the safe management of medicines. Procedures, followed by staff, were in place to help reduce the risks associated with infection. The premises were suitable for people and had been adapted further to meet people’s needs.

Staff told us they felt supported by the provider and the registered manager; staff were trained in areas related to the needs of people using the service. Care needs were assessed and focussed on achieving effective outcomes for people. People had access to other healthcare professionals such as GP’s and speech and language therapists. People were supported to maintain a balanced and nutritious diet and their weight was monitored to ensure it stayed in a healthy weight range.

Staff checked people consented to their care and the principles of the MCA were followed. People contributed to their care plans and as such care plans were personalised and reflected people’s preferences.

Processes were in place to assess any specific needs associated with the Equality Act 2010 so as to help prevent discrimination. Information was provided in an accessible format to people to help them understand choices.

Staff were kind and caring to people and knew them well. People’s independence was promoted. People were supported to maintain their relationships with their relatives and relatives felt welcome when visit

This unannounced inspection was carried out on 17 and 31 July 2017. Churchfield Care Centre provides accommodation nursing and personal care for up to 60 older people. On the day of our inspection visit there were 29 people who were using the service.

The service had a registered manager in place 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.

People were supported by staff who understood the risks people could face and knew how to keep them safe. Some risks to people’s health and safety were not being clearly identified and managed.

People may not be provided with their care and support when this was needed because there were not always enough staff on duty. People may not receive their medicines safely at the time they needed these. People were placed at risk of infection because safe practices were not being followed.

People were being cared for and supported by staff who had been trained to do so. People’s human right to make decisions for themselves was respected and they provided consent to their care when needed. Where people were unable to do so the provider followed the Mental Capacity Act 2005 legal framework to make the least restrictive decisions in people’s best interest. Staff were unaware which people had their freedom restricted lawfully and some people had been restricted by the use of locks on doors.

People were provided with support to have sufficient nutritional and fluid intake. Staff understood people’s healthcare needs and their role in supporting them with these.

People were cared for and supported by staff who respected them. People did not always have their privacy and dignity respected. Where possible people were involved in planning their own care.

People received their care and support in a task oriented manner rather than in a person centred and proactive way. People’s care plans were not always kept up to date and staff rarely referred to these. We have made a recommendation about people having greater opportunities to be involved in activities and follow their own hobbies and interests. People knew how to raise any complaints or concerns they had and these were acted upon.

The management of the service relied on the registered manager’s presence and there were not effective systems to ensure this was maintained in their absence. There were systems in place to monitor the quality of the service and make improvements.

We carried out an unannounced inspection of the service on 19 April 2016.

Churchfield Care Centre provides nursing and personal care accommodation to older people. It is registered for a maximum of 60 people. There were 29 people receiving care and support at the home at the time of our visit.

On the day of our inspection there was a manager who had been in place since September 2015, but they were not 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.

People received their medicines as prescribed. Medicines were stored and handled safely. People told us they felt safe at the home. They were supported by staff who understood how to report allegations of abuse. Risk assessments were in place to identify and reduce the risk to people’s safety. Staff were in place to keep people safe. Staff completed a robust recruitment process to ensure they were safe to provide care for people.

People’s rights were protected under the Mental Capacity Act 2005. People received sufficient to eat and drink, but had to wait long periods for their meal, which meant they may not always have a good experience at mealtimes.

People received effective care, preferences and choices, but staff were not always able to meet their individual needs. People were supported by trained and knowledgeable staff. People were supported to make decisions about their care and treatment. People had access to other healthcare professionals and received effective care, but their care was not always managed appropriately.

People were encouraged and supported to have positive caring relationships with each other, staff as well as their family and friends. People were treated with kindness and compassion. Staff interacted with people in a friendly and caring way. People’s privacy and dignity were protected and people felt able to contribute to decisions made about their care. Arrangements were in place for people to receive support from an independent advocate if they needed one.

People’s care records were person centred and focused on their wishes and respected their views. Staff responded to people’s needs promptly. They encouraged people to participate in activities that were available in the home which reflected their needs. A complaints process was in place and staff knew how to respond to complaints.

The service did not always follow their legal obligation to make relevant notifications to the CQC The quality of the service was sufficiently monitored to make sure people received safe and effective care. The manager supported the staff team in a positive way. Staff felt supported and that the management of the service was approachable and valued them. People and their relatives had opportunities to be involved in the development of the service and share their views.

We carried out an unannounced comprehensive inspection of this service on 17 and 18 February 2015. Breaches of legal requirements were found. We took action against the provider in relation to regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

We also found other breaches of regulations but we did not follow these up at this focused inspection.

We undertook this focused inspection on 27 April 2015 to check that the provider had made improvements to ensure people received their medicines safely and to confirm that they now met the legal requirement. This report only covers our findings in relation to that requirement. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Churchfield Care Centre on our website at www.cqc.org.uk.

The provider had a registered manager in place 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.

Improvements had been made in relation to how medicines were managed and administered to people and regular audits were being carried out to ensure this was sustained. People were now receiving their medicines as prescribed by their doctor. More improvements were needed in relation to the management of medicines in relation to following manufacturer’s guidance and giving staff information about how some medicines were to be administered. This was particularly important for medicines given covertly, which meant the people concerned did not know they were taking them. The registered manager had already commenced clarifying information about this. Further improvements were also needed to ensure all medicines were always stored at safe temperatures.

We had issued a warning notice to the provider following our last inspection on 19 June 2014 for the regulation, 'Cleanliness and infection control'. We did this inspection to check that improvements had been made.

We saw that the provider had taken action to replace carpets, mattresses and some beds. Systems were in place to ensure that people were cared for in a clean environment. We spoke with two people who were using the service and asked if they were satisfied with the standard of cleanliness in the home. One person said, “I am happy with the standard of cleaning. My room is cleaned every day.” Another person told us, “There are lots of new carpets. I think the home is clean enough.”

During this inspection we were also accompanied by a specialist pharmacy inspector who looked at the systems that were in place for the management of medicines. People did not always receive their medicines at the times they needed them and medicines were not kept in a safe way. Medicines were not always correctly administered and recorded properly.

Prior to our visit we reviewed information we had received from the provider. During the visit we spoke with three people who were using the service and six relatives and asked them for their views. We also spoke with staff members and the manager. We looked at some of the records held in the service including the care plans of four people. We observed the support people who used the service received from staff and carried out a tour of the building.

During the inspection we worked to answer five key questions; is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found. The summary describes what we observed, the records we looked at and what people using the service, their relatives and the staff told us.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

We looked at the care plans of four people who were using the service. A care plan describes a person’s care and support needs and gives guidance to staff in how to meet those needs. Where people did not have the capacity to consent, the provider had not always acted in accordance with legal requirements. Assessments of people's capacity to make a particular decision had not been carried out appropriately.

We spoke with three people who were using the service and asked if they felt safe using the service. All of the people we spoke with told us that they felt safe. We also spoke with six relatives of people who were using the service who also indicated they felt their loved ones were safe living at the service. Everybody told us that they would be confident reporting any concerns to the manager.

We carried out a tour of the premises and looked at the standard of cleanliness in several bedrooms, bathrooms and communal areas. We found that the standard of cleaning was not always of an acceptable standard.

The total number of staff employed by the home had increased since our previous inspection. We were told that this had been done so that any sickness and annual leave could be covered by the home’s own staff.

Is the service effective?

We saw that care plans did not always contain sufficient guidance to support staff to be able to meet people’s needs. Repositioning charts were not always completed at the frequency stated in people's care plans which meant we could not be sure people were being provided with the care and support they required.

Is the service caring?

During our inspection we spent periods of time observing the support provided to people in communal areas. We saw that staff interacted with people in a kind and considerate manner. Staff responded to people’s requests for assistance in a timely manner. We saw that staff also responded quickly when a person pressed their call button in their bedroom. Some people required support to eat their lunch and this was provided in a calm and unhurried manner. The lunchtime period was generally relaxed and people appeared to have enjoyed their meals. Staff also provided one person with a birthday cake after lunch, which the person appeared to greatly appreciate.

Is the service responsive?

During our inspection we found a visit report that had been completed by a district nurse in a person’s bedroom. This was dated six weeks before our inspection. We showed the report to the manager and the nurse who were not aware of the district nurse’s visit or the guidance that had been provided. The district nurse had advised that the person should be regularly repositioned. This information was not in the person’s care plan and there was no recorded evidence that the person was being regularly repositioned. This meant that the service had not responded effectively to guidance provided by a healthcare professional.

During our inspection we saw that staff responded in a timely manner to requests for support that people made. Staff also responded quickly when a person pressed the call button in their bedroom.

Is the service well-led?

People who were using the service were asked for their views about the service and they were acted on. We spoke with three people who were using the service and asked if they were aware of ways in which they could provide feedback about the service. One person said they had attended a resident’s meeting. Another person told us, “I know there are meetings but I haven’t attended one. I would just ask to speak to the manager.” We saw that regular meetings were held for people using the service to attend.

A range of audits were being carried out by different staff to assess areas such as cleanliness and the quality of care plans. However the audits had not picked up on and dealt with the areas of concern that we have highlighted in this report.

We used a number of different methods to help us understand the experiences of people who used the service, because the people who used the service had complex needs which meant they were not able to tell us their experiences. We spoke to the relatives of three people and we observed the care of others.

Two relatives told us they felt their relative was being looked after safely, but we found procedures to investigate the possibility of abuse had not been followed and this meant that people were not fully protected from the risk of abuse. We also found people were not fully protected from the risk of infection because appropriate guidance had not all been followed and the environment was not adequately clean and hygienic.

We had received information of concern from two different callers about people's personal care needs not being met in a timely manner by the staff available. During our visit we saw people waiting for assistance with their meal and we found there were less staff provided on that day to meet people's needs than was planned.

There was insufficient information to show how the provider regularly assessed and monitored the quality of service that people received and we have asked the provider for more information about this.

Prior to our visit we reviewed all the information we had received from the provider. During the visit we observed the care people received from staff in both units and spoke with three people who used the service. We also looked at some of the records held in the service including the care files for five people and spoke with managers and various staff.

On our previous visit where we found the provider was not fully complaint in the outcomes we inspected within the nursing unit. During the current inspection we found changes had been made.

We found improvements had been made in the way people's consent was recorded on their files and, where people did not have the capacity to consent, appropriate assessments had been carried out. Staff knew what care was needed and people were satisfied with their care.

We found that everyone received their medicines at an appropriate time in the morning. We spoke to one person, who was able to explain the morning medicines they had been given and told us they were always given on time with breakfast.

The number of permanent staff had increased since our last inspection and some staff had returned after a period of sickness. This meant there were enough staff to meet people's needs. One person told us, "They (the staff) are always around. If you want anything you just have to ask and they help."

We found improvements had been made to use systems to regularly assess and monitor the quality of service that people receive

Prior to our visit we reviewed all the information we had received from the provider. During the visit we spoke with three people who used the service and one relative and asked them for their views. We also spoke with five care workers, the registered manager and the regional manager. We also looked at some of the records held in the service including the care files for four people. We observed the support people who used the service received from staff and carried out a brief tour of the nursing and residential units.

The majority of our time during this visit was spent on the nursing unit where we found the provider was not fully complaint in the outcomes we inspected. We did however visit the residential unit and found the provider to be complaint in the same outcomes.

We found people did not give consent to their care and treatment and did not always receive care and support that met their needs. A person told us, “I haven’t talked with anyone about what care I want.”

We found there were not suitable arrangements for the management of medicines. The provider had not taken steps to ensure there were a sufficient and suitable number of staff available. One person told us“ They (staff) always seem to have too much to do. I think they need more staff.”

We found the provider did not have suitable arrangements to assess and monitor the quality of the service.

This inspection took place on 17 and 18 February 2015 and was unannounced. There were breaches of legal requirements at our last inspection in 2014 and we had been assured by the provider that improvements were made. During this inspection we found some improvements were maintained, but there were still further improvements for the provider to make.

Churchfield Care Centre offers accommodation for to up to 60 people in two separate units, one of which caters for people who require nursing care and the other concentrating on care for people with needs related to dementia. At the time of this inspection there were 40 people accommodated at the home altogether. 27 people were accommodated in the nursing unit of the home and 13 people were accommodated in the residential unit, known by staff as ‘Pine Trees’. There was a manager who had recently registered with the Care Quality Commission (CQC). 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.

We found the medicines were not all well managed and people could not be sure they were receiving them on time and as prescribed by a doctor. Also, there were insufficient qualified nurses employed to cover all shifts safely and there were times when there were not enough care staff to ensure all people were safe.

Staff received regular training and felt supported by other staff and managers.

People had sufficient food and drink and staff gave individual assistance to people to help them with their meals, if needed.

Staff were kind to people and cared about them. We found people’s privacy and dignity were respected and all confidential information was held securely.

Staff were developing ways of improving how to meet the needs of people living with dementia and how to make the environment more stimulating and purposeful for people. Various activities were arranged for people, but they were not always in response to people’s individual interests and preferences.

The quality of the service was not sufficiently monitored in order to ensure people’s care and treatment was always safe, but the registered manager led the staff team with support of senior staff and encouraged a positive culture of honesty and valuing people.

There were some breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 in relation to the management of medicines. There were further breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to staffing, the need for consent and good governance. You can see what action we told the provider to take at the back of the full version of this report.