Archived: Church Lane

Updated 28 September 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service and to provide a rating for the service under the Care Act 2014.

The inspection team consisted of an adult social care inspector. The inspection took place over two days on the 31 August and 4 September 2017.

The provider was given 24 hours’ notice because the location is a small care home for younger adults who are often out during the day; we needed to be sure that someone would be in.

Before the inspection, we asked the provider to complete a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. This was returned within the given timescale.

We also contacted the commissioners of the service and the local authority safeguarding unit who informed us that there were no current concerns about the service. We also spoke to the relatives of the people who used the service.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We observed the care and support to the people who used the service and spoke with their relatives following the inspection. We viewed two people's records relating to their care, support and medication. We spoke with six staff during the inspection.

We looked for a variety of records which related to the management of the service such as policies and procedures, five staff files, training records and quality audits.

Updated 28 September 2017

The inspection took place on the 31 August 2017 and 4 September 2017 and was announced.

Church Lane is a care home service that provides support to people living with autism and or a learning disability, the service is registered to accommodate up to two people.

The service has 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.

We last carried out a comprehensive inspection of this service on 19 April 2016 and breaches of the Health and Social Care Act 2008 were found. After the comprehensive inspection, the registered provider wrote to us to say what they would do to meet legal requirements in relation to safe care and treatment and good governance.

At this inspection we checked that they had followed their plan and confirmed that they now met legal requirements.

Accidents and incidents were recorded and there was a clear investigation process. This meant that themes and trends were highlighted and steps could be taken to reduce the likelihood and risk of further events.

Risk assessments were in place to direct staff in managing specific health conditions that affected the health and welfare of those at the service such as skin integrity, dietary needs and the management of constipation. There were also robust assessments and management plans in regards to environmental risks and those associated with day to day activities.

The registered provider had made changes to the management structure to improve on staff support, career progression and retention. Staff were positive about the changes and felt they were well supported and listened to.

Systems were in place to monitor the quality and safety of service by both the registered manager and the registered provider and these were effective in highlighting and resolving issues.

Information about people’s care needs was stored securely to ensure that people’s confidentiality was maintained.

Staff had an understanding of how to incorporate the basic principles of the Mental Capacity Act 2005 into their day-to-day practice. Each care plan and risk assessment included an assessment of the person’s ability to make a decision around that aspect of their support. Where a person was not able to make an informed decision, it was evidenced that staff were acting in the person’s best interest. Staff had undertaken training about the Deprivation of Liberty Safeguards (DoLS). DoLS had been appropriately applied for the people who needed them which meant that people’s liberties and rights were protected.

There was a record of comments and complaints made about the service. Any actions taken were recorded and this included an apology where necessary.

Staff had a good understanding of people’s care needs. Staff had an in-depth knowledge about the strengths and personalities of those they supported. Care records contained clear and detailed information about the person that enabled staff to understand their preferences and support needs.

People were supported to engage in activities, such as going for walk in the morning, swimming or watching their favourite television programs. The registered manager had started to explore new community based opportunities for those who lived at the service.

Medication records (MAR) were in place and kept up-to-date. The MARs showed that people were supported to take their medication as prescribed.

People’s relatives told us that they felt the service was safe. Staff had received training about safeguarding people from harm and were aware of how to report any concerns. Staff treated people with kindness and patience. We observed that people’s privacy was maintained, for example, during personal care interventions.

The rotas indicated that there were sufficient numbers of staff in place. Recruitment processes were robust and this ensured people’s safety. Staff had the training and support required to enable them to fulfil their roles.

People were supported to access support from external health and social care professionals when required which helped ensure that they stayed healthy.

There was a feedback process for people who used the service. The registered provider had engaged with relatives and staff over some of the changes to the service via meetings and questionnaires.