Churchill Health Care (Luton) received an overall rating of Requires Improvement at its first inspection, with Safe, Effective, and Well-Led domains all requiring improvement due to insufficiently detailed risk assessments, gaps in safeguarding knowledge, weak MCA practice, and ineffective governance audits. Caring and Responsive were rated Good, reflecting a compassionate, personalised service with positive feedback from people and relatives.
Concerns (7)
moderateCare planning: “risk assessments were not always sufficiently detailed to support staff how best to reduce risks”
moderateIncident learning: “a falls risk assessment not being updated following a fall or actions not being noted down to help stop incidents from reoccurring”
moderateSafeguarding: “not all staff we spoke to knew who to report concerns to outside of the organisation, for example to the local authority safeguarding team or the CQC”
moderateConsent / capacity: “one consent to care form was not signed by a person who had the mental capacity to make this decision because they were physically unable sign at the time”
moderateStaff training: “staff received training in the MCA and had their knowledge checked regularly. However, staff found it difficult to explain how this impacted on their job role on a day to day basis”
moderateGovernance: “Audits were not effective in identifying where improvements could be made in all these cases”
minorPerson-centred care: “It was not clear in people's care plans when reviews took place or whether people and relatives were involved in discussions about their care”
Strengths
· People felt safe and expressed satisfaction with the care and support received from kind, compassionate staff
· Sufficient staffing levels maintained with consistent staff teams; no external agency staff used
· Medicines administered safely with staff receiving training and competency checks
· Staff promoted people's privacy, dignity and independence and provided personalised care
· Good infection control practices with appropriate PPE use confirmed by people and relatives
Quality-Statement breakdown (22)
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseRequires improvement
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely care; Supporting people to live healthier livesGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Supporting people to develop and maintain relationships to avoid social isolationGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportGood
well-led: Managers and staff being clear about their roles; quality performance, risks and regulatory requirements; Continuous learningRequires improvement
well-led: Engaging and involving people using the service, the public and staffRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood