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CQC report explained · a residential care home

What the CQC found at Coleridge House

Goodpublished 18 March 2020, 6 years ago

Rated Good: inspectors found the home performing well and meeting their expectations.

The five questions inspectors ask
Safe?
Good
Inspectors found improved infection control, regular safety checks, individual risk assessments, safe medicines management and enough staff. They also found that recruitment checks were completed.
Effective?
Good
Care plans and risk assessments were reviewed, and staff supported people's health, dietary, cultural and faith needs. People were helped to make choices and access healthcare.
Caring?
Good
People had caring relationships with staff and were treated with dignity and respect. Staff supported people's communication, preferences and choices, including preferences about the gender of staff providing personal care.
Responsive?
Good
Support was personalised and helped people maintain family relationships, access the community and take part in activities they enjoyed. Relatives knew how to complain and said they would be listened to.
Well-led?
Good
The home had a registered manager, a clear management structure and regular audits of care, safety and infection control. Staff said they were supported, and people's and relatives' views were used to improve the service.
The latest report, explained

What inspectors found, March 2020

Coleridge House rated Good; inspectors found safe, kind and person-centred care, with improvements since the previous inspection.

The inspection took place on 12 February 2020. One inspector spoke with the person living in the home, people using the agency, relatives and staff. They reviewed care records, medicines, staff recruitment and training records, and the provider's checks on quality and safety.

All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found improvements to infection control, safety checks and quality monitoring. Staff supported people's choices, health needs, diets, relationships and activities.

The previous inspection, published in February 2019, rated the service Requires Improvement and found two breaches of regulations. The provider made improvements, and this inspection found it was no longer in breach.

What inspectors praised
  • Improved safety and hygiene

    Inspectors found that problems identified at the previous inspection had been addressed. The home had better infection control, safer areas and regular records of safety checks.

    “All of the improvements identified at the last inspection had been addressed.” from the report
  • Choice and independence

    People were supported to decide how to spend their time, take reasonable risks and join activities in the community. Staff used the least restrictive approach possible.

    “People were supported to take reasonable risks which enabled them with opportunities to lead a full life.” from the report
  • Respectful relationships

    People and relatives described positive relationships with staff. Inspectors found that dignity, communication preferences and personal choices were respected.

    “People had caring and supportive relationships with the staff who supported them.” from the report
  • Strong quality checks

    The provider had introduced audits and regular reviews of care plans, risks, premises and equipment. Inspectors said these systems were being used to drive improvement.

    “Internal audits were in place to ensure the safety and quality of the service was maintained.” from the report
What inspectors were concerned about

Inspectors raised no specific concerns in this report.

Questions to ask them, based on this report
  1. 01How do you keep infection control, cleaning and safety checks up to date now?
  2. 02How are medicines audited, and what would you do if an error was found?
  3. 03How will you support the person's cultural, faith and dietary needs?
  4. 04What activities and community opportunities could you offer, and how would you support family contact?
  5. 05The report says no one was receiving end of life care at the inspection. What training and arrangements are now in place if this support is needed?

This was a planned inspection covering all five rating areas for the care home and the agency's personal care service; CQC did not inspect agency users who did not receive personal care. This explanation was written from the published report of 18 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.

An earlier report, explained

What inspectors found, February 2019

Rated Requires Improvement; inspectors found kind and responsive care, but safety checks and management oversight at the home were not strong enough.

This was the first rating inspection after a change in registration. Inspectors visited the home without notice on 13 November 2018. They also inspected the agency on 14 November, 4 December and 11 December 2018.

At the home, inspectors found infection control problems, poor maintenance and unsafe garden areas. Quality checks were not effective enough to identify and correct these risks. The home was rated Requires Improvement for Safe and Well-led.

Inspectors found enough staff, safe recruitment, suitable care plans and safe medicines management. People received care that was effective, caring and responsive, and these areas were rated Good. The agency's care was also described positively, although some relatives reported occasional late calls.

What inspectors praised
  • Enough suitable staff

    Staffing levels were sufficient to meet people's care, health, social and cultural needs. Recruitment checks helped ensure staff were suitable to work with people.

    “There were sufficient numbers of staff who were trained in safeguarding to protect people from abuse.” from the report
  • Kind and respectful care

    People were happy with the care. Staff respected privacy, dignity, cultural needs and personal preferences.

    “People were happy with the care and support they received.” from the report
  • Personalised support

    Care plans reflected people's needs, communication methods, interests and routines. They were reviewed when needs changed.

    “Care plans detailed achievable goals which people agreed to and recognised this was to maintain their independence.” from the report
  • Safe medicines support

    Inspectors found medicines were stored and administered safely at the home. Staff had training and checks of their competence.

    “We found that medication had been stored and administered safely.” from the report
  • Responsive agency care

    The agency responded quickly when people needed extra help or a care package restarted. People and relatives said they could raise issues with the office.

    “Two staff came out immediately and made the person comfortable.” from the report
What inspectors were concerned about
  • Infection control

    serious

    The home did not have effective infection control checks. Mops were stored in the kitchen and were not colour coded, while some kitchen surfaces and flooring could not be properly cleaned or disinfected.

    “People were not protected by the control of infection.” from the report
  • Unsafe environment

    serious

    The building and garden were not maintained well enough. Inspectors found damaged flooring, a window that did not close, an overgrown garden, broken furniture and a broken fence.

    “The garden area was unkempt, grass required to be cut to ensure the ground underneath was safe to walk on” from the report
  • Weak quality checks

    serious

    The provider did not have effective systems to monitor safety and improve care. Audits and health and safety checks were missing, irregular or not properly overseen.

    “There was no clearly defined system of internal audits and checks to ensure the safety and quality of service was maintained.” from the report
  • Occasional late agency calls

    needs fixing

    Most relatives were positive about punctuality, but some said staff were occasionally late. The service did not always manage to contact people about delays outside office hours.

    “Most people's relatives were positive about calls being on time however, some relatives said staff were late occasionally.” from the report
  • Limited recording of people's views

    minor

    At the home, people's views about their care and informal discussions about meals were not always recorded. The manager said this would be recorded in future.

    “The person's views about their care were being sought though these were not recorded.” from the report
Questions to ask them, based on this report
  1. 01What has been done to improve infection control, including the storage and colour coding of mops and the cleaning of kitchen surfaces and floors?
  2. 02Has the garden been cleared, made safe and risk assessed, including repairs to the furniture and fence?
  3. 03What regular audits and health and safety checks are now completed, and who reviews the results?
  4. 04How do you monitor whether agency calls are on time, and how do you tell people and relatives about delays?
  5. 05How are people's views about their care and meals recorded and used to make improvements?

The inspection covered both the residential home and the domiciliary care agency, including the home's oral health support; the home was inspected unannounced and the agency was inspected through an announced visit followed by two unannounced telephone-based visits. This explanation was written from the published report of 2 February 2019 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.

The story over the years

Every inspection of Coleridge House

2 rated inspections over a year: the service has improved, from Requires improvement to Good.

  1. March 2020Goodcurrent ratingup from Requires improvement
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good

    Read what inspectors found at Coleridge House →

  2. February 2019Requires improvement
    Safe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement

    Read what inspectors found at Coleridge House →

  3. June 2017

    Registered with the Care Quality Commission on 9 June 2017.

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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