Church Road

Updated 27 March 2020

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

Inspection team

The first day of the inspection was carried out by two inspectors and a member of the CQC medicines team. The second day was carried out by one inspector.

Service and service type

Church Road 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.

The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

The provider completed 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. The provider returned the PIR and we took this into account when we made judgements in this report. We reviewed other information that we held about the service such as notifications. These are events that happen in the service that the provider is legally required to tell us about. We used all of this information to plan our inspection.

During the inspection

As part of our inspection we spoke to one person and one relative about their experiences. Not everyone was able to tell us about their experiences of living at Church Road, we therefore used our observations of people interacting with staff. We also spoke with five members of staff, the registered manager, the deputy manager and the providers operations manager. We reviewed a sample of people’s care and support records. We also looked at records relating to the management of the service such as incident and accident records and complaints. We reviewed medicines systems and records. We looked at eight people’s medicine administration charts, and checked storage arrangements, policies and procedures, and medicines records and audits.

After the inspection

We spoke to five staff members on the telephone. We received feedback from five relatives and requested feedback from four professionals who visited the service. We continued to seek clarification from the registered manager to validate evidence found.

Updated 27 March 2020

About the service

Church Road specialises in the care of people with learning disabilities, autism and physical disabilities. The service is registered to provide care to a maximum of nine people, nine people using the service at the time of our inspection. The service is larger than recommended by best practice guidance. However, we have rated this service good because the size of the service having a negative impact on people was mitigated by the building design. The service was divided into two areas. Church Road Heights provides accommodation for up to four people in self-contained flats. The main home is able to accommodate five people in en-suite bedrooms with shared communal areas. The provider arranged the service in a way that ensured people received person-centred care and were supported to maximise their independence, choice, control and involvement in the community.

People’s experience of using this service and what we found

The service applied the principles and values of Registering the Right Support and other best practice guidance. These ensure that people who use the service can live as full a life as possible and achieve the best possible outcomes that include control, choice and independence. The outcomes for people using the service reflected the principles and values of Registering the Right Support by promoting choice and control, independence and inclusion. People's support focused on them having as many opportunities as possible for them to gain new skills and become more independent.

People had individual activity plans in place based on their assessed needs. We found the activity plans were not always being followed by staff. The provider was aware of this and had plans in place to address it.

The way people’s medicines are managed had improved since our last inspection. People received their medicines in the way prescribed for them. The systems to safeguard people had improved. There were effective governance systems in place to monitor the quality of the service.

There were enough staff available to support people. Staff were recruited safely. Risks to people were identified and guidance was in place for staff to reduce the level of risk to people.

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

Staff received regular training and were knowledgeable about their roles and responsibilities. Staff received one to one supervision and told us they felt supported.

Support plans were detailed and reviewed regularly.

People’s healthcare needs were identified and met. Staff worked with a range of healthcare professionals and followed professional advice and guidance when needed.

People were supported by caring staff who worked towards promoting their dignity, privacy and independence.

We received some mixed feedback from relatives on how they thought their concerns and complaints would be listened and responded to.

People and staff commented positively about the registered manager and deputy manager. We received some mixed feedback from people’s relatives relating to the management of the service and communication. Staff told us the culture of the service had improved.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 18 September 2019). At this inspection we found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Regulation 12, (Safe care and treatment), regulation 13 (Safeguarding service users from abuse and improper treatment) and regulation 17, (Good governance). We also found one breach of regulation 18 of The Care Quality Commission (Registration) Regulations 2009 (Notification of other incidents).

Following this inspection, we served a warning notice for regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We completed a targeted inspection on 21 November 2019 to check the action the provider had taken in response to the regulation 13 breach. At that inspection we found the requirements of the warning notice had been met.

The provider completed an action plan after the last inspection in relation to regulations 12 and 17 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and regulation 18 of The Care Quality Commission (Registration) Regulations 2009 to show what they would do and by when to improve.

At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.