You are here

Archived: Church Green Lodge

The provider of this service changed - see new profile

All reports

Inspection report

Date of Inspection: 5 March 2013
Date of Publication: 11 April 2013
Inspection Report published 11 April 2013 PDF | 67.76 KB

The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care (outcome 16)

Meeting this standard

We checked that people who use this service

  • Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety.

How this check was done

We looked at the personal care or treatment records of people who use the service, carried out a visit on 5 March 2013 and talked with staff.

Our judgement

The provider had an effective system to regularly assess and monitor the quality of service that people receive.

Reasons for our judgement

During our inspection on 20 July 2012 we found that quality systems were not in place at Church Green Lodge.

We found that incidents were not being monitored and that feedback from people using the service was not being analysed so that improvements could be made. We also found that COSHH (Control of Substances Hazardous to Health) assessments had not been reviewed for a significant period of time.

We told the provider of the home that they had to make improvements.

On 20 August 2012 we were forwarded an action plan from the manager of Church Green Lodge which detailed the steps to be taken in order for compliance to be achieved.

The purpose of this inspection, carried out on 05 March 2013, was to ensure that the necessary improvements had been implemented. We found that they had.

The manager showed us a copy of their user feedback folder and we saw that an “action sheet” had been put in place so that any identified areas of improvement could be implemented. The manager told us that the purpose of this action sheet was to ensure that improvements could be monitored. We saw that the most recent feedback received was positive and at the time of our inspection no improvements had been indentified through user feedback. However we were confident that this new system would allow any negative feedback to be recorded and followed up on.

We reviewed the incident reporting system and saw that incidents were recorded and kept in an incident log. We saw that this log was dived into monthly sections and each incident filled under the month to which they corresponded. We were told that relevant incidents were discussed with staff members at team meetings and saw copies of a meeting agenda which confirmed this. However, the provider may find it useful to note that a detailed analysis of monthly incidents could not be produced.

We saw that the COSHH folder has been updated and that a member of the staff team at Church Green Lodge now took responsibility for monitoring this system.