CQC report explained · a residential care home
What the CQC found at 88 Church Lane
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Risks, safeguarding, staffing, recruitment, medicines and infection control were generally managed safely. Inspectors found one missing instruction for a medicine used when needed and one unsigned bruise record.
- Effective?
- Good
- Staff knew people's needs and preferences, had training and support, and followed the Mental Capacity Act principles. People received suitable food, support with healthcare and help to maintain their health.
- Caring?
- Good
- Relatives described staff as kind and caring. Staff respected people's privacy, dignity and choices, and encouraged them to do things for themselves.
- Responsive?
- Good
- Care was personalised and reviewed with people and their relatives. People were supported with communication, activities, community access and contact with their families.
- Well-led?
- Good
- The manager was visible and understood their regulatory responsibilities. Audits were carried out, but inspectors found that monthly weighing had not always happened and some parts of the premises needed refurbishment.
What inspectors found, March 2020
Rated Good; inspectors found safe, kind and person-centred care, with some records and maintenance needing attention.
This was an unannounced inspection on 29 January 2020. One inspector spent time with all five people living at the home, spoke with relatives, staff and the manager, and checked care records, medicines, recruitment files, policies and the premises.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found that people were treated with dignity, supported to make choices, helped to stay healthy and encouraged to develop independence and maintain relationships.
There were some matters needing attention. One medicine used when needed did not have a written instruction, one bruise record had not been signed by the manager, monthly weighing had not always happened, and parts of the building needed work. The manager said these issues would be addressed.
Personalised support
Support was planned around people's individual needs, preferences and communication methods. Staff knew what mattered to each person.
“People using the service received planned and coordinated person-centred support that was appropriate and inclusive for them.” from the report
Safe staffing and risk management
Staffing levels met people's needs, including when people went out. Staff knew about individual risks such as falls, seizures and distress.
“Staff knew about people's risks and the action that was needed to minimise the risks.” from the report
Kind and respectful care
Staff maintained people's privacy and dignity and encouraged independence with everyday tasks.
“Staff ensured people's dignity and privacy were maintained.” from the report
Activities and relationships
People were supported to visit family, go into the community and take part in activities suited to their interests.
“People were supported to maintain relationships and to take part in a range of activities that met their individual needs.” from the report
Missing medicine instruction
needs fixingOne topical medicine prescribed for use when needed did not have a written protocol telling staff when it should be given.
“However, we found that for one topical preparation prescribed on a when required basis no protocol was available.” from the report
Incomplete incident record
needs fixingA body map recording bruising had not been signed by the manager as required. The manager said this would be raised with staff.
“However, one 'body map' form to stipulate where bruising had been identified on a person had not been signed by the registered manager as was requested on the form.” from the report
Missed monthly weighing
needs fixingOne person's records said they should be weighed monthly, but this had not happened every month.
“Records highlighted that one person required to be weighed monthly but this had not been undertaken every month.” from the report
Maintenance work needed
minorInspectors found that parts of the premises needed work, including a stained lounge ceiling and the garden area outside the dining room. A refurbishment plan was in place.
“This included the ceiling in the lounge that was stained and the garden area outside the dining room.” from the report
- 01What written protocol is now in place for the topical medicine prescribed to be used when needed?
- 02How do you make sure bruises and other incidents are reported, recorded and reviewed promptly?
- 03How do you now monitor monthly weighing for people who need it?
- 04What work has been completed under the refurbishment plan, especially to the lounge ceiling and garden area?
This was an unannounced comprehensive inspection covering the care provided and the premises, with all five CQC key questions assessed. This explanation was written from the published report of 27 March 2020 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, August 2017
SENSE - 88 Church Lane is rated Good; inspectors found safe, kind and responsive care, with some staff competency checks still to be completed.
This was an unannounced, comprehensive inspection on 11 July 2017. One inspector visited for one day, met all five residents, observed care and spoke with relatives, staff, the manager and a care professional. The inspector also checked care plans, medicines, recruitment records and quality checks.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, suitable recruitment checks, safe medicines management and staff who understood people's risks and needs.
People were supported with health appointments, food, drinks, communication, activities and family relationships. Staff were described as kind, patient and respectful. The home had remained Good since the previous inspection on 23 July 2015.
There were two areas to keep under review. A new system for checking staff skills had been introduced, but checks had not yet been completed. One agreed care action had been recorded as not achieved several times and needed reconsideration.
Safe staffing and recruitment
Inspectors found enough staff to meet people's needs. Recruitment checks were completed before new staff started, and additional staff were being used for a changed night-time need.
“There were sufficient staff to meet people's needs and the registered provider had established robust recruitment checks to ensure new staff were suitable to work in adult social care.” from the report
Medicines managed safely
Staff were trained and assessed before giving medicines. Inspectors found medicines were given as prescribed, stored safely and checked regularly.
“People could be confident that their medicines were well managed.” from the report
Kind and respectful care
Staff knew people's preferences and communication methods. Inspectors saw patient, caring interactions and respect for privacy and dignity.
“We observed many kind, caring interactions between people and staff throughout the inspection.” from the report
Activities and family links
People had daily activities suited to their preferences and were supported to maintain relationships with family and friends.
“People had access to activities on a daily basis and the relatives we spoke with were happy with the activities their family member took part in.” from the report
Good oversight
The manager was described as approachable. Regular meetings and audits checked safety, care quality and whether actions were being completed.
“The registered manager and the registered provider had developed and utilised a wide range of audits and checks to ensure that the service being offered was meeting people's needs, was safe and meeting the requirements of the law.” from the report
Staff competency checks not completed
needs fixingThe provider had introduced checks to confirm staff had the right skills, but these checks had not yet been completed at the time of inspection.
“The registered manager told us these had not yet been completed but plans were in place to commence these.” from the report
Repeatedly unfinished care action
needs fixingOne agreed action in a person's care plan was repeatedly recorded as not yet achieved. Inspectors said the action might need to be reviewed.
“We saw that for one person an agreed action was repeatedly recorded as not yet achieved.” from the report
- 01Have all staff competency checks now been completed, especially for the specialist needs of people living here?
- 02What was the agreed care-plan action that had not been achieved, and what has been done about it since the inspection?
- 03How will staff understand and respond to my relative's individual communication, sensory and care needs?
- 04How are medicines checked each day and at other regular intervals?
- 05How will my relative be involved in care reviews and decisions if they cannot easily communicate their wishes?
This was an unannounced comprehensive inspection covering all five questions, with ratings compared with the previous Good inspection on 23 July 2015. This explanation was written from the published report of 5 August 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 88 Church Lane
3 rated inspections over 5 years: the service has held its Good rating throughout.
- March 2020Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- March 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 29 November 2010.
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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