Church Green Lodge

Updated 1 June 2018

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked 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 took place on 17 April 2018 and was unannounced. This was a comprehensive inspection carried out by one inspector.

Before the inspection, we reviewed information we held about the service including statutory notifications sent to us by the registered manager about incidents and events that had occurred at the service. Statutory notifications include information about important events, which the provider is required to send us by law. We used this information to plan the inspection. We did not request a Provider Information Return (PIR) form. A PIR is a document that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. We gave the provider an opportunity to provide us with information that was relevant to our inspection.

During the inspection we met five people who lived at the home and four members of care staff, the registered manager and two team managers. If people were unable to tell us directly about their experience, we observed the care they received and the interactions they had with staff.

We looked at three people’s care records, including their assessments, care plans and risk assessments. We checked recruitment and training records and how medicines were managed. We also looked at health and safety checks, quality monitoring checks and the results of the provider’s latest satisfaction surveys.

Updated 1 June 2018

This inspection was carried out on the 17 April 2018. This was an unannounced inspection, which meant the staff and provider did not know we would be visiting.

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

Church Green Lodge is a care home providing short respite accommodation, personal care and support for people who have a learning disability, sensory impairment or mental health conditions. The care home is a ground floor building and is registered to provide care for up to six people. Nobody resides at the care home on a permanent basis. There were six people staying at the home at the time of our inspection.

There was a registered manager in post. 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.

The care service has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.

We last inspected the service in August 2015 and rated the service as 'Good' in all areas and 'Good' overall. At this inspection we found the service remains 'Good' overall, although the rating for the key question of 'is this service effective?' has changed to 'Requires Improvement.' Improvements were required to ensure people’s capacity was assessed, best interest decisions were recorded and consents were obtained in accordance with the Mental Capacity Act (MCA).

We observed people receiving care that was personalised to their individual needs. However care plans did not always reflect people’s needs, preferences and ambitions. The registered manager had identified the need to improve the personalisation of care planning within the service. The registered manager was in the process of updating the care plans and the target for completion was December 2018. This process had been started before our visit and we were able to sample what the care plans would look like once completed. These were more personalised to peoples needs.

Staff understood their responsibilities in safeguarding people from abuse and knew how to report any concerns they had.

Care records contained guidance and information to staff on how to support people safely and mitigate risks. Risk assessments were in place and reviewed monthly. Where someone was identified as being at risk, actions were identified on how to reduce the risk and referrals were made to health professionals as required. People received their medicines safely and as prescribed.

People were supported by sufficient numbers of staff to meet their needs. Robust recruitment procedures were followed to ensure only suitable staff were employed.

People’s needs had been assessed before they moved into the home to ensure staff could provide the support they required. Staff received training considered as mandatory by the provider. All staff attended an induction when they started work and had access to ongoing training. Specific training was provided if people developed needs that required it. The provider supported staff to achieve further qualifications relevant to their roles.

People lived in an environment that was homely and adapted for their needs. The service was clean and hygienic and people had access to communal areas, a garden and their own bedrooms which were individualised. People had been encouraged to choose the décor. Equipment and adaptations were in place to meet people’s mobility needs.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People were able to make choices about the food they ate and were supported to maintain a healthy diet. Staff ensured that individual support guidelines around diet and nutrition were followed.

People were supported to maintain good health and to obtain treatment when they needed it. Staff were observant of any changes in people’s healthcare needs and responded promptly if they became unwell.

Staff were kind, caring and compassionate. People had positive relationships with the staff who supported them and there was a homely, caring atmosphere in the home. Staff treated people with respect and maintained their dignity. They respected people’s individual rights and promoted their independence.

People were supported to make choices about their care and to maintain relationships with their friends and families. People had opportunities to take part in activities that reflected their interests and preferences. People were supported to access the local community and had developed relationships within their community.

There were appropriate procedures for managing complaints. Records demonstrated complaints had been listened to and acted upon.

People, relatives and staff benefited from good leadership. Staff told us the management team supported them well and valued them for the work they did. They told us their suggestions for improvements were encouraged. There was a strong team ethos and staff said they received good support from their colleagues.

People who lived at the home, their relatives and other stakeholders had opportunities to give their views and the provider responded positively to feedback. People’s care records were stored accessibly yet securely. The provider had notified CQC and other relevant incidents of notifiable events when necessary.