CQC report explained · a nursing home
What the CQC found at Church Green Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Staff understood how to report abuse and risks were assessed and reviewed. Inspectors found medicines were given safely, staffing levels were sufficient and recruitment checks were completed.
- Effective?
- Requires improvement
- People's health, diet, training and support needs were generally well managed. However, capacity assessments, best-interest decisions and consent records were not consistently completed in line with the Mental Capacity Act.
- Caring?
- Good
- Staff were kind and respectful. They knew people's communication methods, preferences and routines, and supported privacy, dignity, independence and relationships.
- Responsive?
- Good
- People had activities, community links and support based on their needs and preferences. However, some care plans had unclear and limited information, although inspectors said this had not affected the care being delivered.
- Well-led?
- Good
- The home had a registered manager, regular audits and staff meetings. Managers had identified the need to improve care plans and were working on a more personalised format.
What inspectors found, June 2018
Church Green Lodge was rated Good overall; inspectors found kind, safe care but improvements were needed in consent, capacity and care records.
This was an unannounced, comprehensive inspection on 17 April 2018. One inspector met people and staff, observed care, and checked care records, medicines, recruitment, training, safety checks and quality monitoring.
The home provides short respite stays, personal care and support for up to six people with learning disabilities, sensory impairment or mental health conditions. Six people were staying during the inspection, and nobody lived there permanently.
Inspectors found people were safe, treated with kindness and supported to make choices, stay active and use the local community. Medicines were managed safely, staffing was sufficient, and the home was clean and suitable.
The overall rating stayed Good, as did Safe, Caring, Responsive and Well-led. Effective changed from Good at the previous inspection in August 2015 to Requires Improvement because capacity assessments, best-interest decisions and consent records were not consistently completed.
Safe medicines support
Inspectors found reliable systems for ordering, giving and disposing of medicines. Staff followed written guidance and their competence was checked each year.
“People received their medicines in line with prescription guidelines. There were reliable arrangements for ordering, administering and disposing of medicines.” from the report
Kind and respectful staff
Staff knew people well and understood their individual ways of communicating. They supported dignity, privacy, independence and contact with family and friends.
“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.” from the report
Activities and community links
People took part in activities they enjoyed and were supported to access the local community. Inspectors found people had enough to do.
“People had access to a good range of activities and maintained good strong links with the local community.” from the report
Supportive leadership
Staff described an open and supportive team. Audits and action plans were used to identify and address improvements.
“Quality assurance systems were in place to regularly review the quality of the service that was provided.” from the report
Mental capacity and consent records
needs fixingBest-interest decisions were not always recorded clearly, so it was not always clear why a decision had been made or who had been involved. The home also needed to check whether relatives had legal authority to give consent.
“best interest decisions were not consistently recorded, so it was not clear on people's care plans why the decisions had been made and who had been involved in making the decisions.” from the report
Care plans lacked detail
needs fixingSome care plans were unclear, limited and too uniform. The home had started replacing them with more personalised plans, with a target for completion in December 2018.
“However, we found that care plans contained unclear and minimal information. The management team informed us that they were in the process of reviewing and updating all care plans.” from the report
- 01Have all capacity assessments and best-interest decisions for people using the home now been completed and recorded?
- 02How do you check that a relative has legal authority before accepting their consent for decisions?
- 03Has my relative's care plan been rewritten to include their needs, preferences, ambitions and communication methods?
- 04How will you make sure staff follow the updated care plan during a short respite stay?
- 05What progress has been made on the improvement work that was due to be completed by December 2018?
This was an unannounced comprehensive inspection covering all five key questions; the previous inspection was in August 2015. This explanation was written from the published report of 1 June 2018 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Church Green Lodge
2 rated inspections over 3 years: the service has held its Good rating throughout.
- June 2018Goodcurrent ratingstayed GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- September 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2013
Registered with the Care Quality Commission on 1 November 2013.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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13 live-in carers within about an hour of Norfolk
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £990 to £1,120 a week. 9 can care for a couple. 14 years' experience on average.
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.