CQC report explained · a residential care home
What the CQC found at Colenso House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks were assessed and managed, recruitment checks were completed, staffing levels met people's needs and medicines were managed safely. Infection prevention and premises safety checks were also in place.
- Effective?
- Good
- Staff had induction, training, supervision and support. People were supported with consent, healthcare, food and drink, and their individual dietary needs.
- Caring?
- Good
- Staff knew people well and supported them in a kind, respectful and unhurried way. People were involved in daily choices, and their privacy, dignity and independence were respected.
- Responsive?
- Good
- Care plans were personalised and included people's preferences, cultural needs and routines. The home offered activities, supported contact with relatives and had an accessible complaints process.
- Well-led?
- Good
- Inspectors found an open culture, supportive management and regular quality checks. However, there was no registered manager in place during the inspection, and the new manager was still applying for registration.
What inspectors found, March 2018
Rated Good; inspectors found safe, kind and personalised care, with some management details still being improved.
The announced inspection took place on 27 February 2018. One inspector spoke with staff, one person, relatives and healthcare professionals. The inspector also observed care and checked care plans, medicines records, staff files, rotas, training records and quality checks.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People were supported by staff who knew their needs, preferences and routines. Inspectors found safe medicines management, enough staff, suitable training, respectful care and personalised support.
At the previous inspection in February 2017, the home was rated Requires Improvement. The provider was asked to improve staff induction, medicines management and the risk from contaminated water. Inspectors found these actions had been completed and that the home now met the legal requirements.
Safe medicines
Medicines were given as prescribed, staff had suitable training and records were complete. When-required medicines had guidance explaining when they should be used.
“During this visit we found people had been given their medicines in a safe way and all staff had received appropriate training” from the report
Kind and respectful staff
Staff knew people's needs and preferences and supported them calmly. Inspectors saw positive relationships and respectful care.
“During our visit we saw staff interacting with people in a kind and friendly manner.” from the report
Personalised support
Care plans included people's interests, likes, dislikes, wishes and cultural or religious needs. Staff understood how to support people consistently.
“The care plans also contained information about people's personal interests, likes and dislikes and their individual wishes and preferences.” from the report
Improvements completed
The provider had acted on the problems found at the previous inspection. This included staff induction, medicines management and the contaminated water risk.
“This action had been completed and the provider now met legal requirements.” from the report
No registered manager
needs fixingThere was no registered manager when inspectors visited. A new manager had started and was applying to become registered.
“There was no registered manager in place at the time of our inspection.” from the report
Initial assessments
needs fixingOne assessment was comprehensive, but inspectors said it could contain more information to give a fuller picture of the person's needs.
“We looked at a recently completed assessment and found that although it was comprehensive, more information could be added to make more holistic.” from the report
End-of-life wishes
needs fixingPeople's last wishes had been recorded, but inspectors said the information was not yet detailed enough to make sure those wishes were fully followed.
“However, we found more information could be included to ensure this was met fully.” from the report
Care plan folders
minorThe manager was reviewing the care plan folders because information was not as easy to find as it could be.
“The manager told us that they were in the process of reviewing the care plan folders to make them more user-friendly.” from the report
- 01Has the new manager now completed the application to become the registered manager?
- 02How do you make sure initial assessments contain all the information needed about a person's health, communication and support needs?
- 03How are people's last wishes recorded, reviewed and shared with the staff team?
- 04How do staff find important information quickly in the care plan folders?
- 05How do you check that medicines prescribed for use when needed are given according to the written guidance?
This was an announced inspection of the overall service, including the accommodation and care, and all five CQC questions were rated Good. This explanation was written from the published report of 17 March 2018 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, March 2017
Rated Requires Improvement; inspectors found kind and personalised care, but medicines, emergency planning and management checks were not reliable.
This was the first inspection since the home registered in June 2016. Inspectors visited on 7 February 2017 and spoke with people, staff, relatives and the management team. They reviewed care plans, medicines records, staff files, training records and safety records.
Inspectors found caring staff who respected privacy, supported independence and understood people's needs. People had personalised care plans, activities and support with food, drink and healthcare. Staffing levels were considered sufficient.
There were important safety problems. Medicines were not always given at the prescribed time or in the prescribed way. Shower fittings created a risk of contaminated drinking water, and people did not have personal emergency evacuation plans. New staff did not have suitable induction records.
The overall rating and the ratings for Safe, Effective and Well-led were Requires Improvement. Caring and Responsive were rated Good. The provider was told to take action after four legal breaches.
Kind and respectful staff
Staff built good relationships with people and respected their privacy, dignity and choices.
“Staff maintained people's dignity and respected their privacy.” from the report
Personalised support
Care plans covered people's health needs, food preferences, interests and daily support. People were supported to take part in activities and household tasks.
“People's needs were assessed before they moved into the service. Care and support was delivered in line with their individual care plan.” from the report
Enough staff
Inspectors found enough staff to meet people's needs. Extra staff were available for appointments and social activities.
“There were enough staff working at the service to ensure people's needs were met.” from the report
Food and healthcare support
People had choices about meals and drinks, and special dietary needs were met. Staff supported people to attend healthcare appointments and monitored their health.
“Staff ensured people had enough to eat and drink.” from the report
Medicines were not always safe
seriousSome medicines were not given at the prescribed time or in the prescribed way. There was also no clear protocol for some medicines given when needed.
“medicines were not managed safely as they did not always receive their medicines at the required times and in the way they had been prescribed.” from the report
Drinking water contamination risk
seriousShower heads could fall below the water level or reach the bottom of shower trays. Inspectors said this could allow contaminated water to flow back into the drinking water supply.
“This could create a backflow (an unwanted flow of water in the reverse direction) and could be a serious health risk for the contamination of drinking water, which people and staff consumed.” from the report
No emergency evacuation plans
seriousPeople did not have personal emergency evacuation plans explaining how staff should safely evacuate them in a fire.
“We also found people did not have a Personal Emergency Evacuation Plan (PEEP) in place to ensure they were evacuated safely according to their individual needs.” from the report
Weak staff induction
seriousThe home said it had an induction programme but could not show records or other evidence that it was in place. Inspectors said this could put people at risk of inappropriate care.
“This meant people who lived at the service, were placed at unnecessary risk of harm because staff had not received an appropriate induction.” from the report
Management checks missed problems
seriousThe provider's checks had not identified several issues, including medicines guidance, missing evacuation plans, incomplete references and a fire door problem.
“Despite their internal inspection, our findings during this inspection showed there were areas that required further attention, which were not highlighted by quality assurance audits carried out by the provider.” from the report
Records and complaints information
needs fixingSome records were incomplete, undated or kept at another location. The complaints procedure was not in a format that was easy for people to read and follow.
“However, we noted that the procedure was not adapted to make it easier for people to read and follow.” from the report
- 01What has been changed to make sure every medicine is given at the correct time and in the prescribed way?
- 02Are there now clear protocols for all medicines given when needed, including when they should be used?
- 03What has been done to remove the risk of contaminated drinking water from the shower fittings?
- 04Does every person now have a current Personal Emergency Evacuation Plan, and have staff practised using it?
- 05How do you now check staff inductions, care records, medicines and other safety issues so problems are found promptly?
This was an announced first inspection of the overall service and all five CQC questions; inspectors reviewed two people's records, three staff files, medicines and safety records, and spoke with one person, two staff members and two relatives. This explanation was written from the published report of 29 March 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 Colenso House
2 rated inspections over a year: the service has improved, from Requires improvement to Good.
- March 2018Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2017Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2016
Registered with the Care Quality Commission on 15 June 2016.
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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