CQC report explained · a residential care home
What the CQC found at Kolbe House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Medicines were stored and given safely, risks were assessed and there were enough staff. Inspectors noted that personal emergency evacuation plans were tick-box forms without enough individual detail.
- Effective?
- Good
- People had detailed assessments and care plans, access to healthcare and support with nutrition. Staff were trained, supervised and appraised, and the Mental Capacity Act requirements were followed.
- Caring?
- Good
- People and relatives said staff were kind, respectful and caring. Inspectors observed staff protecting privacy, offering choices and supporting people patiently.
- Responsive?
- Good
- Care plans were personalised and regularly reviewed. Activities were planned around people's needs, complaints were handled through a procedure and end of life wishes were recorded.
- Well-led?
- Good
- The home used audits, meetings and feedback to monitor quality and make improvements. People, relatives and staff described the management as approachable and supportive.
What inspectors found, February 2019
Kolbe House was rated Good; inspectors found safe, kind and personalised care, with a few records needing improvement.
This was an unannounced comprehensive inspection on 9 and 10 January 2019. Inspectors reviewed five care records, five staff files and management records. They spoke with people living in the home, relatives, staff and healthcare professionals.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found that medicines were given safely, risks were assessed, staffing was sufficient and recruitment checks were completed.
People were treated with kindness, dignity and respect. Their care plans, food, activities, cultural needs and end of life wishes were considered. The home had improved since the previous inspection and was meeting all the regulations at this visit.
Inspectors noted two areas needing attention. Personal emergency evacuation plans did not explain each person's individual evacuation needs, and accident records did not include prevention guidance, although the manager said these issues would be addressed.
Safe medicines
Inspectors found that medicines were available, stored securely and administered as prescribed. Records showed no gaps in the medicines administration charts they checked.
“People received their medicines safely and as prescribed.” from the report
Kind and respectful care
People and relatives spoke positively about the care. Inspectors saw staff protect privacy, explain what they were doing and encourage people to remain independent.
“People told us they were happy and well cared for.” from the report
Personalised support
Care plans gave staff clear instructions based on individual needs. People and relatives were involved in discussions and reviews about care.
“Assessments and care plans were person-centred and contained the necessary information for staff to know how to support people and meet their needs.” from the report
Activities and cultural needs
Activities included concerts, exercise, trips, reading, games and dementia-focused materials. The home also respected people's Polish culture and religious needs.
“There were organised activities and these were person-centred and met the needs of people who used the service, including those living with the experience of dementia.” from the report
Improvement since 2017
The home had acted on problems found at the previous inspection. Inspectors found improvements in medicines, risk assessments, care plans, activities, the environment and quality monitoring.
“At this inspection we found that improvements had been made and the provider was meeting all the Regulations.” from the report
Evacuation plans lacked detail
needs fixingPersonal emergency evacuation plans were tick-box forms and did not explain how to support each person according to their individual needs. The manager said this would be addressed without delay.
“However, these were just a tick box form and did not include a narrative to explain how to support people to evacuate according to their individual needs.” from the report
Accident records lacked prevention guidance
needs fixingAccident records recorded what happened and the action taken, but did not include guidance for staff to prevent the problem happening again. The manager said actions were discussed with staff and added to care plans.
“However, records did not include guidelines for staff to follow to prevent reoccurrence.” from the report
- 01Have all personal emergency evacuation plans been rewritten with clear, individual instructions for each person?
- 02How are accident records now reviewed to make sure steps to prevent a repeat are recorded?
- 03How will you make sure medicines administration and PRN protocols remain accurate and regularly reviewed?
- 04How are relatives involved in care plan reviews and decisions about end of life wishes?
- 05What activities are currently available for people living with dementia, and how are their preferences used to plan them?
This was an unannounced comprehensive inspection covering all five key questions and the overall quality of the home. This explanation was written from the published report of 6 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.
What inspectors found, January 2018
Kolbe House was rated Requires Improvement; inspectors found kind care, but medicines, care plans, activities and checks needed improvement.
This was an unannounced comprehensive inspection on 11 December 2017. Inspectors spoke with people, relatives, staff, the manager, a committee member and visiting healthcare professionals. They looked at five care records, four staff files and management records.
The home was caring, with people describing staff as kind, respectful and trustworthy. There were enough staff, recruitment checks were completed, staff were trained, and people had access to food, drink and healthcare.
However, medicines records and administration were not always safe. Risk assessments and care plans did not always explain clearly how people should be supported. Activities did not always meet the needs of people living with dementia, and quality checks had not found these problems.
The overall rating was Requires Improvement. Safe, Effective, Responsive and Well-led were also Requires Improvement. Caring was rated Good. The home had been rated Good overall at the previous inspection in December 2015.
Kind and respectful care
People and relatives gave positive feedback about staff. Inspectors saw staff communicate patiently, offer choices and protect people's privacy and dignity.
“All staff displayed a gentle and patient approach throughout the day when caring for people in the home.” from the report
Enough staff
Inspectors found enough staff on duty to meet people's needs. People said call bells were answered promptly and staff did not appear rushed.
“There were enough staff on duty to meet people's needs in a timely manner.” from the report
Training and support
Staff received training, supervision and yearly appraisals. Training included subjects linked to the needs of people living at the home.
“People were cared for by staff who were well supported.” from the report
Food and healthcare
People had choices of food and drink, and their nutritional needs were monitored. Healthcare visits and advice were recorded in care plans.
“People's health and nutritional needs had been assessed, recorded and were being monitored.” from the report
Medicines records
seriousStaff signatures were missing from some medicines records. Instructions also conflicted, so inspectors could not be sure how some medicines should be given or whether people received them safely.
“This discrepancy meant that we could not be sure how many times a day this medicine was to be administered and if the person was receiving this medicine safely.” from the report
Limited dementia activities
seriousThere were no individual activity plans and little for people to do during the day. Activities were not always suited to people living with dementia.
“There was a lack of activities for people living with dementia and we saw that most of the time, people looked blankly around.” from the report
Checks did not find problems
seriousThe provider carried out audits, but these did not identify the medicines, care planning and dementia environment problems found by inspectors.
“However these audits had not been very effective and had failed to identify the issues we found during the inspection.” from the report
- 01What has changed in the way medicines are recorded and checked since the inspection?
- 02How will you make sure each person's care plan gives clear, individual instructions for staff?
- 03What activities are now available for people living with dementia, and how are these matched to each person's interests and abilities?
- 04How has the environment been improved to help people living with dementia find their way around?
- 05What checks are now used to make sure these improvements are working?
This was an unannounced comprehensive inspection covering all five questions and the overall quality of the home. This explanation was written from the published report of 16 January 2018 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 Kolbe House
3 rated inspections over 3 years: the service has held its Good rating throughout.
- February 2019Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2014
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 13 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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