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Inspection Summary

Overall summary & rating


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 tha

Inspection areas



Updated 28 September 2017

The service was safe.

People were protected from harm and abuse. Assessments had been made to minimise personal and environmental risks to people. Accidents and incidents were reported and investigated appropriately.

People received their medicines when they needed them and in a way that was safe. Medicines were stored safely.

There were enough staff on duty to meet peoples' needs. Appropriate checks were made when employing new staff.



Updated 28 September 2017

The service was effective.

Staff received training, supervision and support to have the skills and knowledge they needed to be effective in their roles.

Staff followed the requirements of the Mental Capacity Act and Deprivation of Liberty Safeguards. Staff understood the importance of gaining consent and giving people choice.

People's health was monitored and staff ensured people had access to external healthcare professionals when they needed it.



Updated 28 September 2017

The service was caring.

Information about people was stored securely.

Staff knew people well, were kind, caring and compassionate and had developed positive relationships with people and their family members.

People were treated with kindness, respect and dignity.

Staff encouraged and supported people to maintain relations with their families.



Updated 28 September 2017

The service was responsive.

Care records gave clear guidance and were reflective of people's individual needs.

People took part in a variety of activities and social events.

People and relatives knew how to raise a concern or complaint and felt listened to.



Updated 28 September 2017

The service was well led.

There was a new registered manager. Staff and relatives were positive about the changes that had recently been made.

There was a quality assurance system with oversight of the service from the registered manager or the registered provider. This was effective in identifying and addressing issues.

CQQ were notified of concerns in line with regulations.