Colenso House

Updated 17 March 2018

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

Following the last inspection in February 2017, we asked the provider to complete an action plan to show what they would do and by when to improve the service to at least good. We did receive a comprehensive action plan within the time allocated to them. We asked the provider to take action to make improvements with regard to staff induction, medicine management and risk of people, visitors and staff consuming contaminated water. This action had been completed and the provider now met legal requirements.

This announced inspection took place on 27 February 2018 and was conducted by one inspector. The manager was given one hour notice because we needed to be sure that members of the management team were available to assist us with the inspection.

Before the inspection, we checked the information that we held about the service. This included statutory notifications sent to us by the registered manager about incidents and events that had occurred at the service. A notification is information about important events which the service is required to send us by law. We also reviewed the information we held about the service and information we had received from other professionals for example the local commissioning team and the care management team.

During our inspection we spoke with the manager, deputy manager and two members of the care staff. We also spoke with one person whose English language was limited. This was done through one staff member who spoke their language in order for us to get their views about the service. The other two people were not able to share their views about the service with us as they had limited verbal communication. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We looked at two care plans, two staff recruitment files, staff training records, staff rotas, staff supervision and a range of records about people's care and how the service was managed. These included medicine administration record (MAR) sheets, satisfaction surveys, quality assurance audits and health and safety records.

After the inspection we spoke on the telephone with three relatives and two healthcare professionals to gain their views about the service.

Updated 17 March 2018

This inspection took place on 27 February 2018 and was announced. At the last inspection on 7 February 2017, the service was rated as requires improvement. We asked the provider to take action to make improvements with regard to staff induction, medicine management and risk of people, visitors and staff consuming contaminated water. This action has been completed.

Colenso is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service provides accommodation and support with personal care for up to five adults with learning disabilities who may also have mental health needs. At the time of our visit, there were three people using the service.

There was no registered manager in place at the time of our inspection. 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.

Relatives and people told us the service was safe and they did not have any concerns.

There were processes in place to minimise risks to people's safety. Staff understood what constituted abuse or poor practice and systems were in place to protect people from the risk of harm. They knew when they should escalate concerns to external organisations. Potential risks to people’s health and well-being were identified and managed effectively.

The recruitment procedures were thorough with appropriate checks undertaken before new staff members started working for the service. There were sufficient numbers of staff available to meet people’s individual needs.

Staff received training and support to deliver a good quality of care to people and a training programme was in place to address identified training needs. Newly appointed staff completed an induction programme.

The manager and staff understood their responsibility to comply with the requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). They respected decisions people made about their care and gained people's consent before they provided care and support.

People received care and support in a compassionate way from a staff team that knew them well and were familiar with their needs. Staff had built a good relationship with people and their privacy and dignity were respected. Confidentiality of people’s personal information was maintained.

People’s dietary needs were taken into account and their nutritional needs were monitored appropriately. Staff supported people to take their medicines safely.

The complaints policy and procedure was accessible to people and their relatives. The manager ensured that any issues raised were resolved to the satisfaction of the person.

The provider had effective systems in place to quality assure the services provided and to drive improvement. Feedback about the service was sought from people, relatives, staff and other professionals. If any improvements were needed, these were implemented.