CQC report explained · a residential care home
What the CQC found at Colne House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People had updated risk assessments, medicines were managed safely and staffing levels were reviewed. Inspectors noted that some staff were not fitting masks correctly and recommended reviewing fire risk assessments for flammable skin creams.
- Effective?
- Good
- This area was not inspected during this focused visit. Its previous rating was carried forward when the overall rating was calculated.
- Caring?
- Good
- This area was not inspected during this focused visit. Its previous rating was carried forward when the overall rating was calculated.
- Responsive?
- Good
- This area was not inspected during this focused visit. Its previous rating was carried forward when the overall rating was calculated.
- Well-led?
- Good
- The manager and staff were described as supportive and open. Audits, feedback and meetings were used to identify improvements and monitor the service.
What inspectors found, April 2022
Colne House was rated Good; inspectors found safe, kind care and improvements since the previous Requires Improvement rating, with some minor safety issues to address.
This was an unannounced, focused inspection on 5 April 2022, followed by feedback on 12 April. One inspector spoke with five people and seven staff, observed care, and checked care, medicines, recruitment and quality records.
The home was rated Good for Safe and Well-led. Inspectors found improvements in infection control, risk management, staffing, medicines and quality checks. People described the home as clean, safe and friendly.
The inspection followed a previous Requires Improvement rating, when legal breaches were found in safe care and treatment and good governance. Inspectors found enough improvement had been made, so the home was no longer in breach.
Friendly atmosphere
People described a homely service and said they liked the staff. Inspectors saw positive interactions between staff and people.
“There was a homely atmosphere, and people told us they were happy with the support provided and liked the staff.” from the report
Improved infection control
Inspectors found better infection control systems and were assured that the home could prevent and manage infections.
“Enough improvement had been made at this inspection and the provider was no longer in breach of regulation 12.” from the report
Safe staffing and recruitment
Staffing levels were reviewed according to people's needs, call bells were answered promptly and recruitment checks had been completed.
“Staff had been recruited safely. Pre-employment checks had been carried out to reduce the risks of recruiting unsuitable staff.” from the report
Medicines managed safely
Trained staff gave medicines, their competency was checked and electronic monitoring helped track doses and stock levels.
“Medicines were managed safely, by trained staff who had their competency checked.” from the report
Better oversight
The manager and senior staff used audits, surveys and meetings to monitor quality and act on feedback.
“Auditing systems and processes were used to identify where improvements were required.” from the report
Mask fitting
needs fixingInspectors were only somewhat assured that personal protective equipment was being used correctly because some staff did not fit masks over their noses. The manager said checks would be carried out.
“Although staff had received training in PPE, not all where ensuring their masks were fitted correctly over their nose.” from the report
Fire risk from skin creams
needs fixingPersonal emergency evacuation plans did not identify the increased fire risk linked to some flammable skin creams. Inspectors recommended that fire risk assessments be updated.
“The PEEP did not alert staff, where people may be at higher risk associated where some skin creams, can make clothing and bedding flammable.” from the report
Oxygen cylinder storage
minorAn oxygen cylinder had not been secured in the medicines room. The manager acted immediately when inspectors raised this.
“Where an oxygen cylinder was stored in the medicines room, it had not been secured to prevent it falling over.” from the report
- 01What checks are now made to ensure all staff fit their masks correctly over their noses?
- 02How have fire risk assessments and evacuation plans been updated for people using flammable skin creams?
- 03Has the new manager's application to become registered been completed?
- 04How are feedback surveys analysed and turned into changes in the service?
- 05How do you check that staffing levels remain enough when staff are off sick or on annual leave?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried over from the previous inspection. This explanation was written from the published report of 30 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.
What inspectors found, April 2021
Colne House was rated Requires Improvement; inspectors found risks in infection control, risk management and service oversight.
This was an unannounced inspection on 26 January 2021, with further inspection activity on 18 February 2021. One inspector observed care, spoke with staff, reviewed records and contacted relatives and professionals.
The inspection began as a targeted check after concerns about staffing, oxygen monitoring, dementia support and infection control. It was widened to a focused inspection of Safe and Well-led because inspectors found concerns about oversight of the service.
Inspectors found that infection control practices were not always safe. Risks linked to people entering other people's bedrooms had not been fully assessed. Staff also lacked effective training and guidance on using pulse oximeters. The home had caring staff and positive feedback from relatives, but its overall rating fell from Good in 2019 to Requires Improvement.
Positive relationships
Relatives described kind and dedicated staff. They said staff kept them informed about incidents and health issues.
“A relative described staff as being, "So loving and caring.” from the report
Medicines monitoring
Electronic checks alerted managers about missed, early or late medicines and when supplies needed reordering. Staff also carried out stock checks.
“The electronic monitoring system was used, which supported them to take action quickly if there were any issues.” from the report
Safe recruitment
The home continued to use recruitment procedures intended to make sure suitable staff were employed.
“The service continued to follow safe recruitment procedures to ensure only suitable staff were employed to work at the service.” from the report
Partnership working
The home worked with health and social care professionals during the pandemic to support people's individual needs.
“During the pandemic the service had been working in partnership with external health and social care agencies to keep people safe and support their individual care needs.” from the report
Infection control
seriousInspectors were not assured that PPE, hand hygiene and enhanced cleaning were always managed safely. They also found that infection risks linked to staff working elsewhere and domestic staff covering care duties had not been robustly assessed.
“Systems were either not in place or robust enough to ensure good oversight and management of infection control.” from the report
Risks from bedroom entry
seriousRisks to people's safety and wellbeing had not been fully assessed when people living with dementia entered other people's bedrooms. Staff did not always respond quickly enough, and there was no effective alert system.
“The impact of people living with dementia entering other people's bedrooms, had not been effectively risk assessed to ensure people's safety and wellbeing.” from the report
Staffing and training
needs fixingStaffing levels fluctuated during the pandemic, and staff said this reduced the time available for social and emotional support. Some refresher training was also incomplete.
“Feedback from staff showed staffing levels fluctuated.” from the report
Weak oversight and communication
seriousQuality checks did not identify some problems. Relatives and staff also reported poor communication and a lack of support during the registered manager's absence.
“Management systems were not robust enough to demonstrate effective quality monitoring or to recognise, identify and mitigate risks to people.” from the report
Missing PRN records
minorThree people did not have forms explaining when medicines prescribed to be given as needed should be administered. The manager said these would be put in place and reviewed.
“We found three people had missing PRN forms.” from the report
- 01What has changed to stop people entering other people's bedrooms, and how are you checking that those risks are now managed?
- 02How do you monitor hand hygiene, PPE use and enhanced cleaning, including after any maintenance or cleaning problem?
- 03What staffing levels are in place for the main home, and how do you cover absences without reducing people's social and emotional support?
- 04How are staff trained and assessed to use pulse oximeters and recognise when medical advice is needed?
- 05What has changed in the quality monitoring and communication systems since the two breaches were identified?
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 17 April 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 Colne House
4 rated inspections over 5 years: the service has held its Good rating throughout.
- April 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2021Requires improvementSafe: Requires improvementWell-led: Requires improvement
- March 2021Inspected but not ratedSafe: Inspected but not rated
- June 2019Goodstayed GoodSafe: Requires improvementWell-led: Good
- December 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2014
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 24 January 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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