CQC report explained · a residential care home
What the CQC found at Collyhurst
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Risks had been identified, but records did not always explain how they were assessed or reduced. Medicines errors, incomplete incident investigations and some infection control problems were found.
- Effective?
- Requires improvement
- Staff had appropriate training and worked with health professionals. However, mental capacity records needed more detail, the mealtime experience needed improvement, and some areas of the home needed refurbishment.
- Caring?
- Good
- People said staff were kind, compassionate and respectful. People were involved in decisions about their care and supported to remain as independent as possible.
- Responsive?
- Good
- Care was personalised to people's needs and preferences. People were supported to keep in touch with family and friends and to take part in activities, while their choices were respected.
- Well-led?
- Requires improvement
- People, relatives and staff spoke positively about the managers. However, quality monitoring did not identify several problems found during the inspection, leading to a breach of Regulation 17.
What inspectors found, April 2022
Rated Requires Improvement; inspectors found kind and personalised care, but safety, medicines and management systems needed urgent improvement.
Inspectors made an unannounced visit on 22 February 2022. They spoke with seven people, two relatives and seven staff. They reviewed care records, medicines records, training records and quality checks.
People generally felt safe and said staff were kind, respectful and responsive. Staffing levels were maintained, people received personalised care, and staff worked with health professionals. However, records did not always explain how risks were reduced, medicines errors occurred, and some areas needed better cleaning and maintenance.
The home was rated Good for Caring and Responsive. It was rated Requires Improvement for Safe, Effective and Well-led, giving an overall rating of Requires Improvement. The report found a breach of Regulation 17 on good governance and asked the provider for an action plan.
Kind and respectful care
People and relatives described staff as kind and compassionate. Inspectors observed positive interactions and found that people's dignity and individuality were respected.
“People told us staff were caring and treated them with kindness and compassion.” from the report
Enough staff
People said staff were available when needed. Staff numbers matched the assessed levels and recruitment checks had been completed.
“Staff told us staffing levels enabled them to look after people safely and records confirmed that assessed staffing levels were maintained.” from the report
Personalised support
Care plans included information about people's lives, communication needs, choices and preferences. People said they could continue activities and routines that mattered to them.
“People received personalised care and told us staff were responsive to their individual needs.” from the report
Health support
Staff monitored people's health and sought medical advice when needed. The home worked with health and social care professionals, including a GP and diabetes nurse.
“The registered managers worked effectively with external health and social care professionals such as the GP who conducted a virtual weekly ward round” from the report
Medicines errors
seriousOne person did not receive a prescribed nutritional supplement for 14 days. Another medicine record was not signed for 14 days, although the stock suggested the medicine had probably been given.
“Errors had occurred due to failures in the systems to support safe medicines practices.” from the report
Risk records and incident follow-up
needs fixingSome records did not explain clearly how risks, including falls, would be reduced. Accident and incident records contained very little information about causes or steps to prevent a repeat.
“However, there was very limited information about investigations carried out to identify the cause, or actions taken to mitigate future incidents from happening again.” from the report
Quality checks did not find problems
seriousAudits failed to identify gaps in risk records, fluid monitoring, medicines checks and infection control. This resulted in a breach of Regulation 17.
“We found no evidence people had been harmed but systems were not established or operated effectively to drive forward improvements.” from the report
Cleaning and maintenance
needs fixingSome areas were cluttered or difficult to clean. Inspectors found a very dirty extractor fan, loose skirting boards, dirty walking frames and a damaged bath panel with sharp edging.
“Some areas of the home did not promote good infection control processes.” from the report
Mealtime experience
minorFeedback about food quality was mixed. Drinks were offered only after meals had been served, and gravy was added without always asking the person.
“However, the mealtime experience required some improvements.” from the report
- 01What changes have been made to prevent missed medicines and incomplete medicines records?
- 02How are falls and other health risks now recorded, reviewed and reduced?
- 03How do managers check that accident and incident investigations lead to action?
- 04What cleaning, decluttering and repair work has been completed since the inspection?
- 05How are residents now asked about meal temperature, drinks and additions such as gravy?
This was an unannounced inspection covering all five key questions, including infection prevention and control and COVID-19 vaccination requirements. This explanation was written from the published report of 15 April 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 Collyhurst
5 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- April 2022Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2021Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- September 2020Inspected but not ratedSafe: Inspected but not rated
- June 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2022
Registered with the Care Quality Commission on 10 February 2022.
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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Fees, photos and reviews from families
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What to check when you visit
At least 100 live-in carers within about an hour of Warwickshire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £950 to £1,260 a week. 77 can care for a couple. 11 years' experience on average.
“If you bump into her in the night on her way to the bathroom she will still inquire how you are and if everything is alright.”
“I have never met a person who is so kind and thinks about others before himself to such an extent as Chris Malagala.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.