CQC report explained · a residential care home
What the CQC found at Colham Road
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- Medicine records and storage were not always managed safely, although inspectors found no evidence that anyone had been harmed. Infection-control procedures were available but were not always followed, including the disposal of protective equipment and cleaning of some areas.
- Effective?
- Good
- People's complex health, nutrition and communication needs were assessed and reviewed. Staff had relevant training and worked with health professionals, although the sensory room was no longer in use.
- Caring?
- Good
- Staff treated people with kindness, dignity and respect. They knew how to understand subtle body language and used different ways to offer choices.
- Responsive?
- Good
- Care plans were personalised, regularly reviewed and followed. People were supported with activities, relationships, cultural needs and end-of-life care, but a lack of dedicated vehicles limited some outside activities.
- Well-led?
- Good
- The management team was described as supportive and open. Audits, meetings and action plans were used to monitor quality and respond to concerns.
What inspectors found, November 2023
Colham Road is rated Good overall, but Safe Requires Improvement because medicines and infection-control procedures were not always handled safely.
Inspectors visited without notice on 10 October 2023. They met all 11 people living at the home, observed care, checked the environment, medicines and records, and spoke with staff, seven relatives and a visiting professional.
The home was caring, effective, responsive and well-led. Staff knew people well, supported communication and choices, provided personalised care, and worked with families and health professionals. There were enough suitably trained staff, with good staff retention.
The main problems were with medicines records and storage, and with some infection-control practices. Some personal protective equipment was put in the wrong bins and some areas needed deep cleaning. The sensory room was also being used for storage, and limited accessible transport reduced some community activities.
The overall Good rating means inspectors found the home was performing well overall. However, Safe was rated Requires Improvement, which means there was limited assurance about safety and an increased risk that people could be harmed. The previous overall rating in 2017 was Good, but the Safe rating fell from Good to Requires Improvement.
Kind and respectful care
Staff were gentle, caring and attentive. They understood how people communicated without words and involved families in decisions.
“The staff interactions with people were kind, supportive and caring.” from the report
Strong health support
The home worked closely with doctors, nurses, dietitians and other professionals. Staff had specialist training for people's complex health conditions.
“The staff worked with other healthcare professionals to make sure people's needs were assessed, monitored, and met.” from the report
Personalised communication
Care plans recorded people's gestures and facial expressions, helping staff understand their wishes, discomfort and choices.
“Staff had created comprehensive communication care plans which recorded different physical gestures and facial expressions and what these meant for each person.” from the report
Medicines records and storage
seriousSome medicine records were not up to date and some medicines were not stored safely. Inspectors found no evidence of harm, but said this increased the risk of errors and harm.
“Medicines were not always managed in a safe way. We identified concerns with some records about medicines and the storage of some medicines.” from the report
Infection-control practice
needs fixingStaff did not always follow the home's infection-control procedures. Some protective equipment went into open wastepaper bins instead of clinical waste bins, and some areas needed deep cleaning.
“There were also some areas which needed deep cleaning.” from the report
Sensory room unavailable
minorThe dedicated sensory room was being used for storage, so people could not use its equipment and resources. The manager said they were trying to raise funds for a replacement facility.
“People living at the service would benefit from regular access to a more suitable sensory facility at the service.” from the report
Limited accessible transport
minorThere were no dedicated vehicles at the time of inspection. Hiring vehicles was possible but costly, which limited access to some events outside the home.
“At the time of the inspection, there were not dedicated vehicles for the service. This limited how easily people could access events outside of the home.” from the report
- 01What has been changed to make medicine records and medicine storage safe and consistently up to date?
- 02How are you checking that staff now dispose of protective equipment correctly and complete the required deep cleaning?
- 03What is the current plan and timescale for bringing the sensory room back into use?
- 04How do you arrange accessible transport, and how often can residents take part in activities outside the home?
- 05What follow-up checks have been completed on the action plans sent to CQC after this inspection?
This was an unannounced comprehensive inspection covering all five CQC questions, including infection prevention and control, with the previous ratings from 2017 reviewed. This explanation was written from the published report of 1 November 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, November 2017
Colham Road was rated Good; inspectors found safe, kind and personalised care, with some staff vacancies covered by agency workers.
This was a comprehensive inspection on 17 and 23 October 2017. Inspectors observed care, spoke with people, staff, relatives and a healthcare professional, and checked care records, medicines, recruitment, training and service records.
The home was rated Good in all five areas: safe, effective, caring, responsive and well-led. Inspectors found positive relationships between staff and people, personalised support plans, safe medicines practice, suitable staff training and good systems for checking quality.
The home had staff vacancies for day and night shifts and relied on some agency staff. Window restrictor checks had not been recorded, but this was dealt with during the inspection. The service remained Good, the same rating as at the comprehensive inspection in September 2015.
Kind and respectful care
Inspectors saw warm relationships between staff and people. Staff respected privacy, dignity and individual preferences.
“We saw that the staff were kind, caring and supportive.” from the report
Personalised support
Care records described people’s needs and preferences. Staff supported communication, choice, independence and individual activities.
“People were supported in ways which met their needs and reflected their preferences.” from the report
Safe medicines
Medicines records were complete for the records checked, and medicine counts matched the records. Staff were trained and assessed as competent.
“The medicine administration records (MARS) we viewed had all been signed by staff and the counts and balances of the medicines we looked at tallied with the information on the MARS.” from the report
Good oversight
The home used audits, satisfaction surveys, meetings and regular management checks to monitor the service.
“There were good systems for auditing the quality of the service.” from the report
Staff vacancies
needs fixingThere were vacancies for day and night staff, so some shifts were covered by agency workers. Staff generally said there were enough people on shift, but one professional reported that staff were sometimes not present when visiting.
“the service did at present rely on some shifts being covered by agency staff.” from the report
Safety checks not recorded
minorWindow restrictor checks had been carried out but were not recorded. The home addressed this during the inspection.
“We were informed that window restrictors were checked but these had not been recorded, this was addressed during the inspection.” from the report
- 01How many day and night staff vacancies are there now, and how often are agency workers used?
- 02How do you make sure agency workers know each person’s needs, preferences and communication methods?
- 03Have all the fire doors been replaced as planned before the end of 2017?
- 04How are window restrictor checks recorded now, and when was the last check completed?
- 05How are relatives involved in care reviews, meetings and decisions about people’s support?
This was a comprehensive inspection covering all five questions and the overall rating. This explanation was written from the published report of 22 November 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 Colham Road
4 rated inspections over 8 years: the service has held its Good rating throughout.
- November 2023Goodcurrent ratingstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2015Goodstayed GoodSafe: Good
- October 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2014
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 9 December 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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