Ensuring ‘Confidence in Care’
through proactive and positive change
Ensuring ‘Confidence in Care’
through proactive and positive change
Thank you for taking an interest in finding out more about all the good work and superb progress that has been underway at Church Rose since the last CQC inspection, which was published by CQC on 9 December 2023.
The following information has been collated to provide transparency and assurance for those considering nursing or residential care at Church Rose for a loved one, to help ensure that such an important choice is fully informed.
About CQC methodology
The CQC is currently undertaking a whole system review of its inspection services, with new methodology yet to be published but expected to come into force early in 2024.
For the MACC Care Group this means that services will no longer be inspected based on CQC’s frequency model in line with the current gradings. CQC continues to regularly inspect services whilst it undergoes transformation and its current decision to inspect is based on knowledge of their locations and through that knowledge, perceived ‘risk.’
Date of last CQC published inspection report – 9 December 2023
Overall rating: Requires Improvement
Key findings indicated that:
- A staff member was observed to wear false nails and another member of staff had a loose religious head scarf which posed an infection control risk.
- Some staff were observed to wear jewellery which posed an infection control risk.
- Documentation did not evidence that equipment had been cleaned between use.
- Conditions relating to deprivations for three residents had not been included within the care plan (although we were able to demonstrate conditions had been met) and statutory notifications made were not submitted in a timely way relating to Deprivation of Liberty outcome assessments.
- The audit systems identified any actions which were required and generated an action plan but action actions had not always been completed in a timely way.
Highlights from the CQC report
The report also identified many positive examples of best practice:
- People and their relatives told CQC they felt safe. One relative was quoted as saying, “I think it is the biggest thing making sure you feel you can leave them and not worry. I visit 2-3 times a week I know they are safe.”
- Staff members had received training in safe processes to support people and meet their known needs.
- We assessed risks to ensure people were safe.
- We ensured there were sufficient numbers of suitable staff, and they operated safe recruitment processes.
- People were supported to receive their medicines safely.
- For people who were assessed as being unable to make their own choices and decisions for themselves, we had explored or obtained evidence people making decisions on their behalf had the necessary authority to do so.
- Staff spoken with were able to explain how they gained consent before supporting people with their care.
- People were supported to eat and drink enough to maintain a balanced diet.
- People’s needs were assessed, and care and support were delivered in line with current standards to achieve effective outcomes.
- Staff members had had received appropriate training and could tell the inspectors how they supported people with their known health conditions.
- We worked effectively within and across organisations to deliver effective care, support, and treatment. People were supported to live healthier lives, access healthcare services and support.
- People’s individual needs were met by the adaption, design, and decoration of the premises.
- People were well supported, and privacy, dignity and independence were respected and promoted and people were supported to express their views and make decisions about their care.
- People were supported as individuals, in line with their needs and preferences.
- We were meeting the Accessible Information standard People’s communication needs were understood and supported.
- People were supported at the end of their life to have a comfortable, dignified and pain free death.
- We promoted a positive and open culture and people, and staff were involved in the running of the service.
- People and relatives knew how to raise concerns and most felt confident any issues would be addressed.
- We had created a learning culture at the service which improved the care people received.
Driving changes for the better
Following the CQC inspection, MACC Care has taken the following steps to improve the service:
- We submitted additional evidence for the inspector to consider which demonstrated that none of our residents had to come to any harm whilst acknowledging that our documentation could have been strengthened.
- An action plan was provided to CQC detailing the immediate actions we had taken during the inspection and as a result how we believed that we were no longer in breach of any regulations.
- Lessons learnt were written and shared with other Managers within the Group so that insights could be shared.
- Immediate changes in practice revert back to the provider’s processes for notifying the regulator of statutory notifications (where these had been changed by the Manager.)
Internal Review processes
Frequent and thorough appraisal of services for your peace of mind
- Internal support teams at MACC Care are on hand to individually support our homes to deliver the best quality resident experience. Additionally, a range of audits are regularly undertaken at both home and organisational level to offer additional quality assurance.
- Internal home audits are completed in line with MACC Care’s Internal Governance Schedule – any patterns or trends are reviewed and added to the home’s service progression plan. This is regularly reviewed to ensure actions are sustained and embedded before they are authorised as closed.
- Insight Reviews have been developed and rolled out (MACC Care’s internal review methodology mapped to CQC’s methodology and regulations) and these are undertaken every six months.
- Follow-up Reviews are undertaken in between Insight Reviews to ensure that any areas for focus are addressed and the change in practice embedded.
- Regular Operational Visits are conducted to support the home manager in service development and a reporting structure is in place to provide organisational assurance.
- Regular visits are also conducted by the Director of Regulation and Director of Operations
- Regular ‘Meet the Manager’ events are held for families and friends of Church Rose.
Friendly, small and welcoming home
Church Rose is delightful, one of the smaller care homes in the MACC Care portfolio, with a really welcoming and homely feel as soon as you walk through the door. The Manager, Mae, is on hand to deal with your enquiries and has a developed a very effective working relationship with other local stakeholders.
Church Rose is currently rated 9.7/10 by significant others
We welcome feedback from our residents and relatives. To view the most recent comments, please the Church Rose page at carehome.co.uk
“I have worked my way up with MACC Care and became Manager of Church Rose in 2021. My key aspiration is to improve quality of life for all under our care – an aspiration that’s shared amongst all staff. With my caring nature, values and experience, I relish the opportunity to make a genuine difference in peoples’ lives.”
Mae Ann Lacson, Church Rose Manager
To find out more about the great things that are happening at Church Rose and the compassionate care and support available to your loved one, please email Mae, or call her on 0121 554 6413.
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