Background to this inspection
Updated
14 May 2020
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.
Inspection team
The inspection was undertaken by one inspection manager and one inspector and a specialist nurse advisor in the care of older people and an expert by experience in the care of older people.
Service and service type
Colbury House is a care home. People in care homes receive accommodation and nursing or personal care as single packages under one contractual arrangement. CQC regulates both the premises and the care provided, and both were looked at during the inspection.
The service did not have a manager registered with the Care Quality Commission. A new manager had been appointed at the end of November 2019 and they had applied to become the registered manager of the service and this was currently in process. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.
During the inspection
We spoke with three people who used the service and four relatives about their experience of the care provided. We spoke with 12 members of staff including the manager, deputy manager, business manager, registered nurses, maintenance, chef, activities coordinator and care staff.
We reviewed a range of records. This included four people’s care records and multiple medication records. We looked at four staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.
After the inspection
We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records. We spoke with two professionals who regularly visit the service.
Updated
14 May 2020
About the service
Colbury House is a residential care home providing personal and nursing care to 39 people aged 65 and over some who may be living with dementia at the time of the inspection. The service can support up to 58 people.
During our previous inspection in December 2018 we identified two breaches of regulations. We issued requirement notices in respect of those breaches. At this inspection we found improvements had been made; however, there was a need to sustain the improvements made and to make further improvements. The service has been rated as requires improvement as it met the characteristics for this rating in most key questions. More information is in the full report.
The previous provider had gone into administration before our planned inspection. A care consultancy company had been brought in by the administrators to assist in the running of the service and to ensure people were kept safe till a new provider had been sought. The care consultancy company had made improvements to keep people safe while they had been managing the service.
People’s experience of using this service and what we found
People told us they felt safe. However, some environmental risks were not managed effectively. Improvements were needed for the safe management of water.
We have made a recommendation about the management of legionella and water hygiene management.
Overall, improvements had been made to the management of risks to people and safety monitoring, but these needed to be further embedded into practice to ensure that people were consistently kept safe from harm.
There were systems in place to monitor the quality and safety of the service provided, however these were not always effective and identifying areas for improvement or where safety had been compromised.
Improvements were still needed to ensure people received person centred care which was responsive to their individual needs.
People felt safe living at Colbury House Nursing Home, and they were very much at the heart of the service. We received positive feedback from people and their relatives about the care provided.
There were plans in place for foreseeable emergencies. Staff were able to tell us how to keep people safe.
Relevant recruitment checks were conducted before staff started working at the service to make sure they were of good character and had the necessary skills.
Staff had received training in safeguarding adults and knew how to identify, prevent and report abuse. There were enough staff to keep people safe.
Medicines administration records (MAR) confirmed people had received their medicines as prescribed.
Staff received support and one to one sessions or supervision to discuss areas of development. They completed training and felt it supported them in their job role.
People were supported with their nutritional needs. People received varied meals including a choice of fresh food and drinks. Staff were aware of people’s likes and dislikes
People were treated with kindness and compassion. Staff were able to identify and discuss the importance of maintaining people’s respect and privacy at all times.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
The provider’s quality assurance system helped the management team implement improvements that would benefit people. Action had been taken to become compliant with one of the breaches of regulation identified at the previous inspection.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was requires improvement (published 22 January 2019) and there were two breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made; however, there was a need to sustain the improvements made and to make further improvements
Why we inspected
This was a planned inspection based on the previous rating.
We have found evidence that the provider needs to make improvement. You can see what action we have asked the provider to take at the end of this full report.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.