You are here

Inspection Summary


Overall summary & rating

Requires improvement

Updated 16 January 2018

We undertook an unannounced inspection of Kolbe House on 11 December 2017. The service was last inspected on 7 December 2015, when we rated the service Good overall.

Kolbe House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Kolbe house provides accommodation and personal care for up to 25 older people predominantly from the Polish community. There were 22 people living at the service at the time of our inspection.

The service is required to have a registered manager and there was a registered manager in post at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Staff did not always follow the procedure for recording and the safe administration of medicines. This meant that people were at risk of not receiving their medicines safely.

The provider had a number of systems in place to monitor the quality of the service and put action plans in place where concerns were identified. However, audits had failed to identify the areas for improvement that we found during the inspection.

The risks to people's wellbeing and safety had been assessed, but there was not always enough information on people’s records about how to mitigate these risks.

People's needs were assessed prior to receiving a service and care plans were developed from the assessments. However, assessments and care plans did not always contain the necessary information for staff to know how to support people and meet their needs and were not always written in a person centred way.

There were organised activities. However these were not always person-centred and did not always meet the needs of people living with dementia.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 which related to Safe Care and Treatment, Person Centred Care and Good Governance. You can see what actions we told the provider to take at the back of the full version of this report.

There were procedures for safeguarding adults and staff were aware of these. Staff knew how to respond to any medical emergencies or significant changes in a person's wellbeing.

Staff received training in infection control and there were systems in place to protect people from the risk of infection.

The provider ensured that lessons were learned when things went wrong. They had systems in place to manage incidents and accidents and took appropriate action to minimise the risk of reoccurrence.

The service employed enough staff to meet people's needs safely and had contingency plans in place in the event of staff’s absence. Recruitment checks were in place to obtain information about new staff and ensure they were suitable before they started working for the service.

The registered manager was aware of their responsibilities in line with the requirements of the Mental Capacity Act 2005 (MCA) and staff had received training on this. People’s capacity to make decisions about their care and treatment had been assessed. Processes had been followed to ensure that, when necessary, people were deprived of their liberty lawfully.

People's health and nutritional needs had been assessed, recorded and were being monitored. People gave positive feedback about the food and told us they were offered choice. People had access to healthcare professionals as they needed, and their visits were recorded in people’s care plans.

Staff received effective training, supervision and appraisals. The registered manager sought guidance and support from other healthcare professionals and attended workshops and provider forums in order to keep abreast of developments within the social care sector and shared important information with staff.

People told us they felt safe at the home and trusted the staff. They told us staff treated them with dignity and respect when providing care and treated them with kindness. Relatives and professionals we spoke with confirmed this. We saw people being cared for in a calm and patient manner.

There was a complaints procedure in place which the provider followed. People felt confident that if they raised a complaint, they would be listened to and their concerns addressed.

People, staff and relatives told us that the registered manager and senior team were approachable and supportive. There was a clear management structure, and they encouraged an open and transparent culture within the service. People and staff were supported to raise concerns and make suggestions about where improvements could be made.

Inspection areas

Safe

Requires improvement

Updated 16 January 2018

The service was not always safe.

Staff did not always follow the procedure for the recording and safe administration of medicines. This meant that people were at risk of not receiving their medicines safely.

The risks to people's wellbeing and safety had been assessed, but there was not always enough information on people’s records about how to mitigate these risks.

There were procedures for safeguarding adults and staff were aware of these.

There were enough staff on duty to meet people’s needs in a timely manner. Checks were carried out during the recruitment process to ensure only suitable staff were being employed.

Effective

Requires improvement

Updated 16 January 2018

The service was not always effective.

The environment was not designed in a way to support people who were living with the experience of dementia.

People’s care and support had been assessed before they started using the service. However, assessments we viewed were basic, lacked detail and were not always written in a person centred way.

The registered manager was aware of their responsibilities in line with the requirements of the Mental Capacity Act 2005 and understood its principles. People had consented to their care and support.

People were supported by staff who were well trained, supervised and appraised.

People's health and nutritional needs had been assessed, recorded and were being monitored. People were protected from the risks of inadequate nutrition and hydration. People had a choice of food and drink for every meal, and throughout the day.

Caring

Good

Updated 16 January 2018

The service was caring.

Feedback from people and relatives was positive about both the staff and the management team.

People and relatives said the care workers were kind, caring and respectful. Staff knew people well and had developed a trusting relationship with them.

Care plans contained people’s background and their likes and dislikes. People were supported with their individual needs in a way that reflected their diversity, values and human rights.

People and their relatives were involved in decisions about their care and support.

Responsive

Requires improvement

Updated 16 January 2018

The service was not always responsive.

People's individual needs had been assessed and recorded in their care plans prior to receiving a service, and were regularly reviewed. However, care plans did not contain enough detail for staff to know how to meet peoples’ needs and were not always written in a person centred way.

There were organised activities. However these were not always person-centred and did not always meet the needs of people living with dementia.

There was a complaints policy and procedures in place. People knew how to make a complaint, and felt confident that their concerns would be addressed appropriately.

Well-led

Requires improvement

Updated 16 January 2018

The service was not always well-led.

The provider had a number of systems in place to monitor the quality of the service and put action plans in place where concerns were identified. However, medicines audits and other checks carried out by the provider had failed to identify the issues we found.

The service conducted satisfaction surveys for people and their relatives. These provided vital information about the quality of the service provided.

People and their relatives found the management team to be approachable and supportive.

The provider encouraged good communication with staff and people who used the service, which promoted a culture of openness and trust within the service.