CQC report explained · a nursing home
What the CQC found at Cole Valley
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People and relatives said they felt safe. Inspectors found enough staff, safe medicines management, safeguarding processes, infection control and suitable recruitment checks.
- Effective?
- Good
- Staff had training and competency checks, and people received support with food, drink, healthcare and oral hygiene. The home had improved its work under the Mental Capacity Act and DoLS processes.
- Caring?
- Good
- People and relatives described staff as kind and caring. Inspectors saw respectful support, involvement in care decisions and encouragement to remain independent.
- Responsive?
- Good
- Care plans reflected people's needs and preferences. People had access to activities, support with communication and personalised end-of-life plans.
- Well-led?
- Requires improvement
- The new management team had made clear improvements, but governance systems were not fully effective. Inspectors found delayed health guidance and incomplete pressure-care records, so further work was needed to make the improvements consistent.
What inspectors found, February 2023
Rated Good overall and no longer in special measures; inspectors found kind, safe care, but management systems still needed improvement.
Inspectors visited without notice on 11 and 12 January 2023. They spoke with four people, seven relatives or representatives and 11 staff. They observed care and reviewed care, medicines, recruitment and management records.
The home was rated Good for Safe, Effective, Caring and Responsive. Inspectors found enough staff, safe medicines practices, suitable training, kind care, personalised support and activities. People were involved in decisions and supported to maintain their independence.
Well-led was rated Requires Improvement. New systems had been introduced, but they were not yet fully embedded. Inspectors found delays in providing guidance about one person's health condition and incomplete pressure-care records, although this did not affect the care provided and action was taken during the inspection.
The previous overall rating was Requires Improvement and the home had been in special measures since 10 June 2021. The provider had previously breached Regulations 11 and 17. At this inspection, the breaches had been addressed, the overall rating was no longer Inadequate and the home left special measures.
Safe staffing and medicines
Inspectors found enough staff to meet people's needs. Medicines were stored, given and recorded safely, with extra information for medicines given when needed.
“Medicines were managed safely and in line with good practice guidance.” from the report
Kind and respectful care
People and relatives said staff were kind and caring. Inspectors saw respectful interactions and found that people's dignity, choices and independence were supported.
“We saw kind and respectful interactions between staff and people.” from the report
Personalised support and activities
Care plans included people's preferences and staff knew people well. Activities were varied, and staff spent time with people who stayed in their bedrooms.
“The care provided was person centred and reflected what was important to people” from the report
Improvement under new management
The new registered manager and management team had made improvements to care records, medicines, consent processes and environmental checks. Relatives and staff reported a positive change.
“The new registered manager had made positive changes in the service and was supported by the provider and staff team.” from the report
Management checks and records
needs fixingThe governance system was not fully reliable. Guidance about one person's health condition was delayed and pressure-care records were incomplete, increasing the risk that staff might not follow the required care.
“The provider's governance system was not entirely effective and there had been a delay in ensuring staff had access to guidance about 1 person's specific health condition, and to ensure 1 person's records in relation to pressure care were fully completed.” from the report
Improvements still need to settle
needs fixingInspectors said the new systems needed more time to become established, especially as the number of people using the home increased.
“These changes required further embedding to ensure they remained effective as the home grew.” from the report
- 01What checks now make sure staff have the right guidance for each person's specific health conditions?
- 02How are pressure-care records checked for completeness and accuracy?
- 03How will you make sure the new management systems remain effective as more people move into the home?
- 04How are medicines, care plans and risk assessments reviewed after any incident or change in need?
- 05How are people and relatives involved in reviewing care plans and raising concerns?
This was an unannounced focused inspection to check improvements after earlier breaches, and it also included infection prevention and control checks under Safe. This explanation was written from the published report of 18 February 2023 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, June 2022
Rated Requires Improvement and kept in special measures; inspectors found serious weaknesses in how the home was managed.
Inspectors visited unannounced on 24 and 28 March 2022. They spoke with people living at the home, relatives and staff. They reviewed care records, medicines records, staff files and management records.
Some improvements had been made since the last inspection. The home had enough staff during the visit, people said they felt safe, infection control had improved and the environment had been partly refurbished. However, medicines were not always given at the right time, some risks had not been dealt with quickly and care records were not always up to date.
People were not always supported in line with the Mental Capacity Act. Records did not consistently show that people had been assessed for specific decisions or that restrictive actions were in their best interests. Oral hygiene support was also not consistently provided.
The overall rating changed from Inadequate to Requires Improvement, but the home remained in special measures because it had been rated Inadequate in a key question at two consecutive inspections. Well-led remained Inadequate, showing widespread and significant shortfalls in leadership and oversight.
Enough staff during the visit
Inspectors observed enough staff to meet people's needs. Relatives described a calm atmosphere and staff responding to people.
“Our observations were there were enough staff to meet people's needs.” from the report
People felt safe
People and relatives said they felt safe. Staff had safeguarding training and understood how to report concerns.
“There was a calm atmosphere within the home and people and relatives told us they felt safe.” from the report
Food and mealtimes
People said they were happy with the food. Inspectors saw a relaxed atmosphere at mealtimes, and people's choices about where to eat were respected.
“Our observations were there was a relaxed atmosphere at mealtimes with staff and people talking together and people appearing to enjoy their food.” from the report
Some improvements since the previous inspection
Risk assessments for equipment had improved, nurse competency checks had been completed and parts of the home had been refurbished.
“At this inspection we found improvements had been made to meet the previous breach in the regulations under safe care and treatment.” from the report
Poor management oversight
seriousThe home's audits and governance systems did not find or fix repeated problems. This was a continued breach and the same concern had appeared over several inspections.
“The provider's oversight of the service had been ineffective to identify and address concerns.” from the report
Consent and restrictive care
seriousDecision-specific capacity assessments and best-interests decisions were missing for some restrictions. A relative had signed consent forms without the legal authority to do so.
“We found the provider was not consistently working within the principles of the MCA and people's rights under the MCA were not protected.” from the report
Medicines timing
seriousSome time-specific medicines, including insulin, were not always given when prescribed. At the time of the inspection there was no reliable system to record when these medicines were given.
“Where people were prescribed insulin to control their diabetes, they were not always supported to take it at the time they needed it.” from the report
Unresolved environmental risks
seriousRisks involving Legionella, oxygen storage, hazardous substances and a stair gate had not always been dealt with promptly. Some were addressed during or after the inspection.
“Where environmental risks had been identified the provider had failed to take timely action to address the concerns.” from the report
Care records and oral hygiene
needs fixingSome care plans did not contain current professional guidance or enough person-centred information. Oral hygiene support was not consistently recorded or delivered to people's assessed needs.
“One person's care plan hadn't been updated following an assessment from Speech and Language Therapists (SaLT) and their most recent recommendations were not in the person's care plan.” from the report
Agency staff and training gaps
needs fixingThere was a high use of agency care staff. Inspectors also found gaps in training and staff knowledge about the Mental Capacity Act, Deprivation of Liberty Safeguards and supporting people who may show aggression.
“There was a high use of agency care staff during the day.” from the report
- 01Have all people who may lack capacity now had decision-specific capacity assessments and recorded best-interests decisions?
- 02How do you now check that insulin and other time-specific medicines are given at the prescribed time?
- 03What action has been completed to deal with the Legionella, oxygen storage, hazardous substances cupboard and stair gate risks?
- 04How are care plans checked so that professional advice, including speech and language therapy advice, is kept up to date?
- 05What has the new quality manager changed, and how will you show that repeated problems are now being identified and fixed?
This was a focused inspection of Safe and Well-led, widened to include Effective; Caring and Responsive were not inspected and their previous ratings were used in calculating the overall rating. This explanation was written from the published report of 9 June 2022 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 Cole Valley
8 rated inspections over 8 years: the service has held its Good rating throughout.
- February 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2022Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementWell-led: Inadequate
- August 2021InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- December 2020Inspected but not ratedSafe: Inspected but not rated
- September 2019Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- May 2019Inadequatestayed InadequateSafe: InadequateEffective: InadequateCaring: InadequateResponsive: InadequateWell-led: Inadequate
- April 2019Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- April 2017Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2015GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- October 2013
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- June 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 26 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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