Factual accuracy comments form
Please complete this form and return:
By email to: [email protected] or
By post to: CQC ASC Inspections, Citygate, Gallowgate, Newcastle upon Tyne, NE1 4PA
What does your challenge relate to?
Go direct to:
Typographical/numerical errors
Section A
Accuracy of the evidence in the report
Section B
Completeness of the evidence
Section C
Conduct of the inspection
Complaints via email to [email protected]
Representations against a Warning Notice
Representations via email to [email protected]
Account Number:
Our reference:
Location name:
Location address:
1-128946870
INS2-2945204400
Church View Nursing Home
Rainer Close, Stratton St Margaret, Swindon, Wiltshire, SN3 4YA
Completed by (name(s))
Sue Houldey
Position(s)
Operations Director and Responsible Individual
Date
17/03/2017
Section A: Typographical / numerical errors in the draft report
Page
No
Key
Question
e.g. Safe
Please set out any typographical or numerical errors
e.g. Operations Director not Operations Manager
If the same error occurs more than once, it is sufficient to
identify the first occasion, adding “(throughout the report)”.
CQC
decision
or X
CQC response
Section B: Other challenges to the accuracy of the evidence in the draft report
Page
No
3
Para
1
Key
Question
e.g. Safe
Summar
y
Please set out any other challenges to the accuracy of the
evidence in the draft report (providing evidence
demonstrating the inaccuracy) and describe any impact on
the rating(s). Challenges to the interpretation of
evidence/importance attributed to the evidence should be
included here. Any evidence provided must relate to the
position on the day of inspection.
A matrix of progress in respect of MCA/Best interests was
sent to the inspector post inspection as agreed during
verbal feedback. There appears to have been no
consideration or reference to this document made
throughout the body of this report.(Appendix 5)
CQC
decision
or X

CQC response
If you agree to make amendments you must
confirm any impact on breaches or the rating.
If you choose not to make any amendments you
must provide a rationale.
Reference to the information, which was sent
after the inspection, regarding the MCA and
best interest decisions, is identified in the text
of the effective domain. However, we will
amend the report to identify this in the main
summary.
3
Para
5
3
Para
8
4
Summar
y
Summar
y
Safe
Robust audits have been noted throughout the report as
having been undertaken. These quality assurance
processes identified the medication errors referred to.
Speedy robust performance management was
implemented further to our investigations with a number of
dismissals being made with subsequent referral to
regulatory bodies.
x
It is the provider’s contention that this is evidence of safe
and effective practice and strong leadership. The
opportunities for such errors exist in all care homes and it
was the effectiveness of the QA processes that enabled us
to respond effectively. We do not believe that this has
been fairly reflected within the body of the report.
We note from the last inspection report that some
x
commentary was made in respect of capacity and best
interests. No breach in respect of care and treatment was
identified in this report. It is the provider’s contention that
the matrix of progress in respect of MCA/Dols/Best
interests shows a significantly improved set of outcomes.
We recognise that under Regulation 14 enforcement
action was taken, however this was in relation to meeting
nutrition and hydration needs
We would further contend that to identify our approach as
seen during the course of the recent inspection as being a
breach is inconsistent with the commentary in the last
report, subsequent conditions and the progress made to
date.
Please refer to our previous commentary
x
Whilst it is reflective of clear auditing and
strong leadership that the medicine errors
were identified and appropriately addressed,
staff had not followed procedures for the
errors to have occurred. It is acknowledged
the ‘opportunities for error’ does exist to
some extent. However, robust systems and
safe practice minimises this. These factors
were not evident and staff made errors which
should not have occurred. No amendments
to the report will be made.
It is acknowledged that progress is being
made in response to complying with the
MCA. However, information was sent after
the inspection and as quite rightly stated, the
area had been raised at a previous
inspection. Despite this, some shortfalls
remained. No amendments to the report will
be made.
It is factually accurate that staff had not
followed procedures when administering
medicines and errors had occurred. No
4
Effective
Please refer to our previous commentary.
We find it inconsistent that the grading remains unchanged
despite the significant evidence provided at the time of the
inspection, and in correspondence after the inspection as
agreed with the lead inspector
5
Respons
ive
It is the providers view that significant improvements have
been made in this KLOE, however the grading remains
unchanged despite significant evidence of sustained
improvement in this regard
x
5
Well-led
It is our contention that the rating of requires improvement
is not balanced and reflective of the findings of the
inspector or inspector feedback post inspection.
x
7
Para
3
Safe
In the report it is stated that there was no guidance to
inform staff what they should do in the event of
temperatures not being within appropriate range.

amendments to the report will be made.
Whilst improvements had been made, there
remained some shortfalls regarding
compliance with the MCA, which was
reflective of the “requires improvement”
characteristics of the adult social care ratings
guidance. No amendments to the report will
be made.
As stated within the report, it was
acknowledged that improvements had been
made to the responsiveness of the service.
However, some areas required further focus
and time was needed to ensure all
improvements were properly embedded and
sustained. The information within this domain
is reflective of the “requires improvement”
characteristics of the adult social care ratings
guidance.
It is acknowledged that improvements had
been made to the service and this is reflected
throughout the report. However, some areas
required further focus and whilst
improvements had been made, this had been
within a short time frame and not evidenced
over an extended period of time. The
information within this domain is reflective of
the “requires improvement” characteristics of
adult social care ratings guidance.
The manager told the inspector they did have
guidance regarding the action to take if the
refrigerator or medicines room was above or
below a certain temperature, but it was not
This is not the case as there was a clear policy accessible
for all staff in each unit informing them exactly what to do
in this event. Copy was provided as evidence to one of
the inspectors on the day of the inspection. (See Appendix
1)
displayed. The maintenance person put a
copy of this on the front of the medicine
fridge. We will amend the report to clarify the
guidance was available but not originally
displayed.
7
Para
4
Safe
In the report it identifies protocols lacked detail and were
not person centred. This aspect was not brought up at the
feedback session or during the inspection. Each protocol
is individual to each resident and highlights the specific
medication they are on. The protocol also highlights a
resident’s allergy(s) and contraindications for that
medication. Therefore we would argue that protocols are
person centred in this regard. (Appendix 2)
x
8
Safe
In the report it is stated that the assessments were

As identified at the start of the feedback
session, it was stated the discussions would
not cover every aspect of the inspection
findings. Shortfalls within protocols were
identified within the written account of the
main findings, sent the day after the
inspection. Whilst the information within
Appendix 2 is noted, protocols looked at
during the inspection were not sufficiently
detailed. For example, the PRN protocol for
EJ for Codeine, did not state the maximum
dose or the minimum period of time between
intervals of it being given. There was no
information regarding the purpose of the
medicine and the format stated ‘please be
specific if resident is not able to verbally
communicate’. EJ was unable to clearly
verbally communicate. The PRN protocol for
SB for Lorazepam identified the medicine
was to be given for agitation/seizures. It did
not describe detail of potential signs and
symptoms to trigger the medicine’s
administration. This did not ensure a
consistent approach from staff. No
amendments to the report will be made
We will remove this information from the
Para
3
8
Para
3
Safe
9
Para
3
Safe
11
Para
2
Effective
reviewed on a monthly basis as per condition report, but
review dates were difficult to identify. This was inaccurate
as the care plan system automatically gives a review date
and the “RAG” System highlights if a review is out of date.
The support manager showed the inspectors how the care
plan system worked on the day. (Appendix 3)

In relation to review times for assessments: Please see
our comments above about Care Sys automatically
generating the flags. “Resident of the day” had also been
introduced to further support this process. It should be
noted that the special measures status has been removed
from this home further to its compliance with the conditions
imposed upon it, which include the assessment and care
planning process.

The report describes call bell response times and implies
some delays during specific periods. The inspector has
been provided (via a complaint response) with evidence of
our review of call bell response times which spanned a full
week covering both days and nights. The home was
satisfied that the response to all call bells was within
acceptable limits and no specific variation was noted
between days and night.
The inspector was reminded at the inspection of this
complaint and acknowledged the extent and findings of the
review undertaken

The report states that records did not show how the
person had been supported to consent to these
restrictions. However, the inspectors did not pick up on
the fact that care and treatment consent forms had been
completed for the majority of the residents in the home.
report.
As above, we will remove this information
from the report.
This paragraph identifies people’s views
about staff availability and response times to
call bells. Whilst the complaint response
showed response times were satisfactory to
the provider, people who used the service
may not have been in agreement. We will not
remove people’s comments but will add
details of the recent audit and the provider’s
views about call bell response times, to the
report.
Whilst consent to care and treatment forms
were noted, these did not cover specific
restrictions. We will amend the report to
show work was progressing in this area.
This evidence was provided immediately after the
feedback session. (Appendix 4) Any resident that lacked
capacity has had a DOLS application submitted which
indicated restrictions in that persons best interest and the
home manager signs the consent form to indicate that next
of Kin had also been informed of the current restrictions in
place.
11
Para
3
Effective
12
Para
1
Effective
The inspector was emailed a MCA/Best Interest Matrix
that identified those aspects that had been carried out on
each resident and highlighted those who had previously a
care and treatment consent form in place (a matter which
had not been picked up by the inspector) (Appendix 5)
Information in regards to covert medication was verbally
agreed but it did not state who or what other measures
were in place to enable consent. However all residents
that require covert medication had a Covert protocol in
place which had been agreed in the persons best interest
This included the involvement of the GP, Pharmacist and
Home Manager. In addition there is a risk plan also in
Residents care plans (Appendix 6)
x
The report states “Records showed the person had
x
capacity but documentation did not show the person
understood the detrimental effect their decisions might
have on their health.” It should be noted that records
show that the resident was involved in decision making
processes in regards to his health and medical condition. It
is the view of the provider that where there is evidence of
capacity and in line with principles of person centred care,
the home will enable and respect resident decision
making.
This was in relation to ES’s records. The
inspector asked a registered nurse about the
agreement but they were not able to give any
detail about the process other than it had
been agreed by the GP. The supporting
manager was asked for documentation
regarding a capacity assessment and best
interest meeting but this was not provided.
No amendments to the report will be made.
Whilst it is acknowledged the person was
involved in decision making, there was
limited evidence to show they fully
understood the choices they were making or
the potential consequences of their
decisions. This particularly applied to their
pressure ulceration and resistance to care.
Whilst it is recognised people should be able
to make unwise decisions, processes to
assure capacity and enable informed
See Caresys entry from Diary. (Appendix 7)
12
Para
5
Effective
13
Effective
Note that the regime described asserting that the resident
is making unwise decisions must be placed within the
context of current understanding of type II diabetes
management. The resident from time to time chooses to
eat biscuits or other snacks. Current guidance does not
prohibit eating such snacks but requires the management
of carbohydrates across the full dietary intake of the
person concerned.
We seek clarity about the findings within the report in
respect of supplements recording, given the demonstrably
evidenced improved outcomes for residents
In respect of supervision: A comprehensive matrix was
decision making, should be evidenced. This
was not identified in relation to this person.
No amendments to the report will be made.
x

The improvements in the monitoring of
people’s food and fluid intake are stated
within the report. However, supplements and
snacks were not consistently evidenced. For
example, within NM’s food chart dated
23.1.17 it was stated they had one teaspoonful of porridge for breakfast and four
tea spoonfuls of pureed meat, mash, broccoli
and cauliflower for lunch. They declined their
dessert of sponge and custard and had 4 tea
spoonfuls of pureed meat and mixed
vegetables for tea. They had half a
strawberry delight for dessert and the record
showed half a yoghurt, as a snack. The time
of this was not stated. No alternatives or
other snacks throughout the day were
identified. There were supplements in the
person’s room but no evidence of these
being given on 23.1.17 despite limited food
intake. This was the same on 25.1.17. No
amendments to the report will be made.
The matrix showing the occurrence of staff
Para
3
14
Para
2
Effective
made available the inspector at the point of inspection
which clearly showed complete compliance with company
policy. In addition to the documents held at the home,
chronologies and documents are held by our HR partner in
respect of supervisory contact which has a disciplinary
context. It should be noted that in all cases of performance
management and or disciplinary our HR partners have
been satisfied that these documents have been sufficient
to be robustly defended in a legal arena. It is therefore the
providers contention that the supervision process,
performance management and effective use of disciplinary
procedures are entirely appropriate to meet both the
needs of the service and the development of personnel
The report states “a person with diabetes had blood
glucose levels, which were consistently higher than the
normal range, but this was not being actively managed”.
This was not the case, CARESYS record disproves this
(See Appendix 7)
This shows evidence of multidisciplinary approach to care
and management of this individual. The provider has
consistently evidenced through the conditions process and
at the inspection that all chronic diseases had been logged
and cross referenced against a valid care plan. The overall
surveillance of chronic disease management is jointly
undertaken by registered nurses, our GP and any other
relevant members of the MDT.
In respect of two staff being unable to discuss the detail of
diabetes management, we would draw the inspectors
attention to the inaccuracies of observations made in
respect of diabetes made by the inspector. Outcomes for
diabetic residents at Church View House have never been

supervision sessions was acknowledged
during the inspection and we will add this to
the report. However, records of the sessions
to show the ongoing support and
development of staff and those areas
discussed were not available. This meant it
was difficult to identify any required actions
and whether these had been completed.
Whilst more detailed records were available
regarding those staff who were subject to
disciplinary procedures, this was not the case
with the remainder of the team. No further
amendments to the report will be made.
The wording of this area within the report will
be amended as it is not accurate. It was
noted the person’s blood glucose levels were
being checked three times a day and this
showed they were consistently high. The
person had been referred to the Specialist
Diabetic Nursing Service after their arrival at
the home. However, further advice had not
been sought in response to the continued
high blood glucose levels. A registered nurse
confirmed this.
15 all
para’
s and
16 all
paras
Caring
17
Para
2
Respons
ive
the subject of any concern by any member of the MDT
team.
This section within the report gives clear evidence of
person centred care being accepted by the inspector
which significantly contradicts references to a lack of
person centred approach elsewhere within the body of the
report. Not least Well-Led, Effective and Responsive
The provider would appreciate the identification of the
individual indicated to be made reference in order that we
can provide further evidence.
x

The evidence within the caring domain is
specifically related to staff involving and
treating people with compassion, kindness,
dignity and respect. During the inspection,
there were many areas which demonstrated
this. However, there was less evidence of a
person centred approach in areas such as
the planning and delivery of care.
Management confirmed this by explaining
they had worked hard to ensure the service
was safe and were now focusing on the
additional level of person centred care. No
amendments to the report will be made.
This person had the initials RP.
The reason for the request in this regard is particularly
important as we would need to identify whether or not the
resistance described by the inspector was a new
behaviour or one previously identified.
17
para
5
Respons
ive
We would further observe that the management of
pressure wounds and importantly the incidence of wounds
being acquired within the home is a particularly strong
feature of the significant improvements that have been
made in respect of our responsiveness.
The provider maintains that whilst the individual is
described as being resistive to care it is clear that the level
of resistance demonstrated, is acknowledged by the
x
The view that the person’s resistance to care
(particularly repositioning) was not sufficient
to compromise the overall management of
inspector as “sometimes”. This resistance has not been
sufficient enough to compromise the overall management
strategy for the maintenance of their skin integrity. In order
to inform any such plan a reference point of any such
behaviours, which includes established baselines,
frequency and nature would need to be clarified in order to
inform any robust assessment and planning process. In
order for care plans to be truly person centred the care
plan must reference observations that are specific and
measurable and set in absolute context of overall
presentation and risk.
the person’s skin is disputed. The person had
a grade 2 pressure ulcer on their sacrum and
although it was healing, the care plan had not
been amended to reduce the risk of further
damage. In addition, there was a risk of
ulceration re-occurring in the future. No
amendments to the report will be made.
We would suggest that the staff response to this matter
may have been to demonstrate a responsiveness to the
inspectors.
20
Para
2
Well Led
The wound audits undertaken by the manager and
Operations team and subsequent declaration within the
managers monthly report indicate that the surveillance of,
and responsiveness to skin integrity compromise is a
strong feature of the clinical responsiveness of the service
(by definition person centred)
We note that CQC defines the characteristics of a “Good”
rated Well led service as follows
“People, their family and friends are regularly involved with
the service in a meaningful way, helping to drive
continuous improvement. People’s feedback about the
way the service is led describes it as consistently good.
The service has a clear vision and set of values that
include honesty, involvement, compassion, dignity,
independence, respect, equality and safety. These are
x
Whilst the characteristics of the “Good” rating
are acknowledged, some shortfalls were
identified and there was other work that was
“in progress”. It is clearly recognised and
identified in the report that improvements had
been made. However, following the low
baseline which was inherited, further focus
and time is required to fully embed such
practice and to ensure consistency. This is
reflective of the “requires improvement”
understood and consistently put into practice.
The service has a positive culture that is person-centred,
open, inclusive and empowering. It has a well-developed
understanding of equality, diversity and human rights and
put these into practice.
Staff have the confidence to question practice and report
concerns about the care offered by colleagues, carers and
other professionals. When this happens they are
supported and their concerns are thoroughly investigated.
Staff understand their role, appreciate what is expected of
them, are happy in their work, are motivated and have
confidence in the way the service is managed. Managers
are consistent, lead by example and are available to staff
for guidance and support. They provide them with
constructive feedback and clear lines of accountability.
Support and resources are available to enable and
empower the staff team to develop and to drive
improvement.
The service defines quality from the perspective of the
people using it and involves them, staff and external
stakeholders in a consistent way. Quality assurance
arrangements are robust and the need to provide a quality
service is fundamental and understood by all staff. Where
required, processes are in place to enable managers to
account for actions, behaviours and the performance of
staff.
The service works in partnership with key organisations to
support care provision, service development and joined-up
care.
Legal obligations, including conditions of registration from
CQC, and those placed on them by other external
organisations are understood and met.”
characteristics of adult social care ratings
guidance. No amendments to the report will
be made.
We would argue that these characteristics have been
robustly achieved as detailed in commentary throughout
the body of this report. It is the provider’s contention that
there is sufficient evidence within the draft report to
support a grading good for Well Led. Specifically we refer
you to the following sections within the draft report:
Page 7 – Para 2 and 5
Page 8 – Para 4, 5 and 7
Page 9 – Para 2, 4, 5 and 6
Page 11 – Para 4
Page 12 – Para 6
Page 13 – Para 1, 2, 4 and 5
Page 14 – Para 1, 2 and 3
Page 15 ad 16 in its entirety
Page 18 – Para 3, 4 and 5
Page 19 – Para 1 and 2
Page 20 – Para 2, 3 4 and 5
Page 21- para 1, 2, 3, 4 and
Page 22 – para 1, 2 and 3
And our commentary as noted above with regard to each
section within the report
Section C: Additional relevant evidence that should be taken into account (“completeness”)
Page
No
Key
Question
e.g. Safe
Please describe (and provide copies of) any additional
evidence which you consider should be taken into account
in the report. Evidence must relate to the position on the day of
inspection.
CQC
decision
or X
CQC response
If you agree to make amendments you must
confirm any impact on breaches or the rating.
If you choose not to make any amendments you
must provide reasons.
CQC use only
Responses prepared by (name)
Alison McDonald
Role
Inspector
Date
26 April 2017
Responses reviewed by (name)
Justine Button
Role
Inspection Manager
Date
02/05/2017