CQC report explained · a residential care home
What the CQC found at Collingtree Park
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, August 2022
Collingtree Park rated Good after inspectors found clear improvements, with some people still waiting for staff and mixed views about the food.
This was an unannounced focused inspection on 28 July 2022. Two inspectors spoke with people, a relative, staff and managers. They also checked care records, recruitment files, audits and action plans.
Inspectors looked at Safe, Effective and Well-led. They found people felt safe, medicines were given correctly, infection control was followed and there were enough staff during the visit. Staff were trained and understood people's needs. People were supported with food, health care and decisions about their care.
The home had previously been rated Requires Improvement, with breaches of regulations. Inspectors found the required improvements had been made and there were no current breaches. The overall rating changed to Good, but Caring and Responsive were not inspected in this visit and their earlier ratings were carried forward.
People felt safe
People said they felt safe, and safeguarding systems were in place. Accidents and incidents were recorded, reported and followed up.
“Systems and processes were in place to safeguard people from harm.” from the report
Safer medicines practice
Trained staff gave medicines accurately and used the correct records and guidance, including information about patches.
“Medicines were administered accurately by trained staff. We saw records which showed the correct information recorded when medicines were given, along with appropriate guidance.” from the report
Staff support and training
Staff received induction, ongoing training and supervision. Inspectors found that staff understood people's needs.
“Staff demonstrated an in-depth knowledge of the needs of people using the service.” from the report
Management improvements
The management team had introduced better audits, record keeping and action plans. Staff and relatives described positive changes.
“There have been massive improvements. The manager is helpful and around quite a bit. There is always someone around.” from the report
Some delays in getting staff
minorAlthough inspectors found enough staff during the visit, some people said they were sometimes left waiting. Ask how staffing levels are monitored at busy times.
“The staff all work hard, but sometimes you can be left waiting a bit.” from the report
Mixed views about food
minorPeople were generally happy and had choices, but inspectors recorded mixed views about the quality of the food.
“People we spoke with told us they had mixed reviews on the quality of food, but were generally happy and were offered choice.” from the report
No registered manager at the visit
minorThere was a manager in post who was applying to register, but no registered manager was in place when inspectors visited.
“At the time of our inspection there was not a registered manager in post.” from the report
- 01How are staffing levels checked during busy periods, and how do you prevent people being left waiting?
- 02What changes have been made to the food following the mixed views about its quality?
- 03Has the manager completed the registration process, and who is responsible for the home until then?
- 04How are you checking that the improvements to safeguarding, medicines, risk assessments and records continue?
- 05How do you assess and respond to people's personal preferences and daily needs, given that Caring and Responsive were not inspected in this visit?
This was an unannounced focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 17 August 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.
What inspectors found, December 2021
Rated Requires Improvement; inspectors found risks around injuries, care records, medicines, staffing and management oversight.
This was an unannounced focused inspection on 12 October 2021. Inspectors reviewed Safe and Well-led because concerns had been raised about staffing, infection control, records and care plans. They spoke with people, relatives and staff, observed care, and checked care, medicine, recruitment and management records.
Inspectors found unexplained injuries were not always investigated and records did not consistently show that injuries were followed up. Risk assessments, repositioning, drinks, thickener and medicine records were not always complete or consistent. Staffing levels were often below the provider's own planned numbers, and observations showed people could wait for help with eating and drinking.
The home had safe recruitment, staff training and some effective infection control arrangements. People and relatives knew how to complain and felt listened to. However, the systems used to check records, medicines, accidents, staffing and cleaning had not identified or corrected the problems. The overall rating fell from Good at the previous inspection, published in 2018, to Requires Improvement.
Safe recruitment
The provider used references and DBS checks when recruiting staff. Inspectors found recruitment practices were safe.
“Safe recruitment practices were in place and the provider used references and the Disclosure and Barring service (DBS) to ensure staff did not have any criminal convictions and were suitable to provide support for the people living at the service.” from the report
Infection precautions
Inspectors were assured about PPE, testing, visits, social distancing and managing infection outbreaks.
“We were assured that the provider was using PPE effectively and safely.” from the report
Working with health professionals
The home made referrals to relevant health professionals when people needed support and followed their advice.
“We saw evidence of staff and management working with health professionals and following advice.” from the report
Unexplained injuries
seriousSome injuries had no recorded cause or investigation. Injury records also lacked enough detail to show whether injuries were healing.
“Unexplained injuries were not investigated. For example, we found one person had a bruise on their forehead recorded, another person had a bruise on their mouth and bruises to both arms and head recorded.” from the report
Incomplete risk and care records
seriousRecords did not consistently show that people received repositioning, drinks and other planned care. This could increase risks such as pressure damage, dehydration and choking.
“Records of care tasks were not completed consistently, which put people at risk of not receiving the support they required to keep safe and healthy.” from the report
Medicine recording
seriousMedicine records did not consistently show where skin patches were placed. Records about thickener were conflicting and its use was not always recorded.
“Medicine administration recording required improvement. People who required support with transdermal patches did not consistently have the placement of the patch recorded.” from the report
Staffing levels
seriousRotas did not always meet the home's planned staffing numbers, especially at weekends. Inspectors saw delays in helping people with food and drink.
“Lunchtime observations evidenced there were not enough staff to support the people who required help with eating and drinking in a timely manner.” from the report
Weak management checks
seriousAudits had not found or acted on several problems in records, medicines, staffing, accidents and cleaning. This meant leaders did not have reliable oversight of people's safety.
“The provider had failed to assess, monitor and mitigate risks relating to health, safety and welfare of people using the service.” from the report
Cleaning records
minorThe home appeared clean, but there were no records showing that high-touch areas were cleaned during the day and cleaning schedules had gaps.
“There were no records of high touch areas being cleaned throughout the day and cleaning schedules had gaps in the records.” from the report
- 01How are unexplained injuries now investigated, recorded and followed up until they have healed?
- 02How do you check that repositioning, drinks, oral care and other daily care tasks are completed and recorded?
- 03How do you ensure medicine patches and thickener are administered and recorded correctly?
- 04What staffing levels are now provided on morning, evening and night shifts, including weekends?
- 05What actions have been completed in response to the Regulation 17 warning notice, and how are you checking that they work?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not inspected and their previous ratings were carried over. This explanation was written from the published report of 10 December 2021 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 Collingtree Park
4 rated inspections over 7 years: the service has held its Good rating throughout.
- August 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- February 2018Goodstayed GoodSafe: GoodEffective: GoodWell-led: Good
- December 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2014
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- February 2011
Registered with the Care Quality Commission on 15 February 2011.
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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