CQC report explained · a residential care home
What the CQC found at 14 Church Lane Avenue
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People had risk assessments, suitable staffing and trained staff. Medicines were given as prescribed and records had no gaps. A recent legionella test had not been completed before the inspection, but this was arranged during the visit.
- Effective?
- Good
- Care needs were assessed and reviewed, and staff received training for both general care and individual needs. The home worked with health professionals and followed the Mental Capacity Act principles.
- Caring?
- Good
- Inspectors found kind and respectful relationships. Staff supported people's privacy, dignity, choices and independence, including people who communicated without speech.
- Responsive?
- Good
- Care plans were detailed and personalised. People were supported with communication, activities, community trips, relationships and religious interests, and relatives could give feedback or raise complaints.
- Well-led?
- Good
- The manager was closely involved in care and had oversight of quality and safety. Staff and relatives described an open, warm and friendly culture, with changes made in response to feedback.
What inspectors found, December 2019
Rated Good; inspectors found safe, kind and personalised care, with one recent legionella testing shortfall addressed during the visit.
This was a planned, announced inspection of a small care home for up to two people with learning disabilities. Inspectors spoke with staff and the manager, observed care because the two residents could not speak with them, and checked care, medicine, staff and management records. They also contacted relatives and professionals.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough suitable staff, safe medicine systems, detailed care plans, good links with health professionals, and care that respected people's dignity, choices and independence.
The home had not completed a recent legionella test when inspectors arrived. Water temperature checks had been done, and the manager arranged for the test to be completed during the inspection. The previous inspection, published in April 2017, had also rated the home Good.
Personalised care plans
Care plans included people's histories, preferences and support needs. Staff said the plans gave them clear information about how to provide care.
“People had support plans which were individual to them, information in them included their life histories, preferences, likes and dislikes and their support needs.” from the report
Dignity and independence
Staff supported people to make choices and do as much as possible for themselves. Inspectors observed privacy, dignity and independence being promoted.
“We observed staff promoting people's independence and respecting their privacy and dignity.” from the report
Good health support
The home worked with several health professionals and shared information to meet people's individual health needs.
“We noted in people's care files that there was effective joint working and communication with other agencies to meet people's individual needs.” from the report
Active management
The manager was directly involved in care and used checks, feedback and team discussions to identify improvements.
“There was a governance system in place to ensure there was appropriate oversight of the service to identify improvements needed.” from the report
Legionella testing
minorA recent legionella test had not been completed when inspectors visited. Water temperature checks were in place, and the manager arranged a test during the inspection.
“We noted that the provider had not had a recent legionella test completed, however water temperature checks to ensure safety had been carried out.” from the report
- 01Has the legionella test arranged during the inspection been completed, and what were the results?
- 02How would you adapt the care plan to my relative's communication needs, preferences and health risks?
- 03What activities and community opportunities would be suitable for my relative?
- 04How do you check that medicines are given correctly and that records remain complete?
- 05How are relatives involved in care reviews and decisions made under the Mental Capacity Act?
This was a planned inspection covering all five CQC questions, including the premises and the care provided; the previous ratings from 2017 were reassessed and remained Good. This explanation was written from the published report of 28 December 2019 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.
What inspectors found, April 2017
Rated Good; inspectors found safe, kind and personalised care, with all five areas rated Good.
This was an announced, comprehensive inspection on 5 April 2017. The inspector observed care, spoke with the manager and two staff members, reviewed records and medicines, and checked staffing, training, safety and quality systems. Feedback was also received from two relatives and a social care professional.
The home supports two people with autism and learning disabilities. Inspectors found enough staff, safe medicines management, suitable risk assessments and a clean environment. Staff knew people's communication methods, needs and preferences well.
People were supported with food, healthcare, activities, family relationships and daily living skills. Inspectors found caring relationships, respect for privacy and dignity, person-centred care plans and good management oversight. The overall rating was Good, and all five individual areas were also rated Good.
The home was rated Good at the previous inspection in October 2014, and inspectors found that it remained Good at this inspection.
Staff know people well
The staff team was stable, with many staff having worked at the home since it opened. Inspectors found that staff understood people's likes, dislikes, personalities and communication.
“The registered manager and staff knew people really well. There was a very stable staff team in place; most staff had worked at the home since it had opened 10 years ago.” from the report
Safe staffing and medicines
The rota provided the one-to-one support people needed. Staff were trained and assessed as competent to give medicines, which were stored and recorded safely.
“There were enough staff to keep people safe and meet their needs. The rota was planned to ensure that people received the 1:1 care they needed.” from the report
Kind and respectful care
People's privacy, dignity and choices were respected. Staff built positive relationships and supported people to stay in contact with family and friends.
“Staff had developed positive and caring relationships with people. Companionable, relaxed relationships were evident during the day of our inspection.” from the report
Personalised support and independence
Care plans explained how to support each person, including their communication and daily living goals. People were encouraged to make choices, learn skills and take part in household tasks.
“People received care that was personalised to their needs. People's needs had been assessed before they moved into the home to ensure staff could provide the care and support they needed.” from the report
Good management checks
The home used regular audits and checks covering care records, incidents, health and safety, food safety and infection control. Records were organised and up to date.
“There was an established system of quality monitoring that ensured people received good quality care and support.” from the report
Inspectors raised no specific concerns in this report.
- 01How will staff recognise and respond to my relative's individual communication methods, including gestures and body language?
- 02How is one-to-one staffing arranged on every shift, and what happens if a planned member of staff is absent?
- 03How are my relative's activities and independence goals reviewed and updated when their interests or abilities change?
- 04What mental capacity assessments, best-interest decisions or Deprivation of Liberty Safeguards applications would apply to my relative?
- 05How will the home support contact with family and access to healthcare professionals?
This was an announced comprehensive inspection covering all five key questions, following a previous Good rating in October 2014. This explanation was written from the published report of 28 April 2017 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 14 Church Lane Avenue
3 rated inspections over 5 years: the service has held its Good rating throughout.
- December 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 11 January 2011.
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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