6 February 2019
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.
This comprehensive inspection took place on 9 and 10 January 2019 and was unannounced.
On 9 January 2019, the inspection was carried out by one inspector and an expert by experience who undertook interviews with people and their relatives. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service.
On 10 January 2019, the inspection was carried out by a member of the CQC medicines team.
Before the inspection, the provider completed a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. We reviewed the information we held about the service, including notifications we had received from the provider informing us of significant events that occurred at the service. Notifications are for certain changes, events and incidents affecting the service and the people who use it that providers are required to notify us about.
During the inspection we looked at the care records of five people who used the service, five staff files and a range of records relating to the management of the service, such as incident and accident records, audits, fire safety checks and medicines management.
We spoke with seven people who used the service, two relatives, one visitor, the registered manager, the care manager, the assistant manager, a senior care assistant and two care assistants. We also spoke with a visiting healthcare professional who was regularly involved in the care of people who used the service. We emailed a social care and a healthcare professional, and received one reply.
6 February 2019
The inspection took place on 9 and 10 January 2019 and was unannounced.
The last inspection took place 11 December 2017, when we found breaches of Regulations relating to safe care and treatment, person centred care and good governance. Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions of ‘Is the service safe?’, ‘Is the service effective?’, ‘Is the service responsive?’ and ‘Is the service well-led?’ to at least good. The provider supplied us with an action plan on 22 January 2018 telling us that they would complete the necessary improvements by July 2018. At this inspection we found that improvements had been made and the provider was meeting all the Regulations.
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.
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 followed the procedure for the recording and safe administration of medicines and people were receiving their medicines safely and as prescribed.
The risks to people’s wellbeing and safety had been assessed and there were detailed guidelines on people’s records about how to mitigate these risks.
There were procedures for safeguarding adults and staff were aware of these. They knew how to respond to medical emergencies or significant changes in a person’s wellbeing.
People were protected from the risk of infection and cross contamination and staff received training in infection control.
The provider ensured that lessons were learnt when things went wrong. There were systems in place to manage incidents and accidents and appropriate action was taken to minimise the risk of reoccurrence.
The provider employed enough staff to meet people’s needs safely and there were contingency plans in the event of staff absence. Recruitment checks were carried out to ensure that new staff were suitable before they started working for the service.
People’s needs were assessed prior to receiving a service and care plans were developed from the initial assessments. Assessments and care plans were person-centred and contained the necessary information for staff to know how to support people and meet their needs.
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 in 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.
The provider had consulted relevant guidance and taken steps to improve and develop the environment to meet the needs of people who used the service, in particular those living with the experience of dementia.
People were supported by staff who were appropriately trained, supervised and appraised. The registered manager sought guidance from a range of healthcare professionals and attended meetings and provider forums in order to keep abreast of developments within the social care sector. Important information was cascaded to staff to ensure they were kept informed and felt valued.
People told us they were happy and well cared for. They said that staff treated them with kindness, dignity and respect at all times. Relatives and professionals we spoke with confirmed this. People’s end of life wishes, cultural and religious needs were respected and met.
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.
There was a complaints procedure which the provider followed. People felt confident that if they raised a complaint, they would be listened to and their concerns addressed.
The provider had effective systems in place to monitor the quality of the service and put action plans in place where concerns were identified.
People, staff and relatives told us the registered manager and senior team were approachable and supportive, and there was an open and transparent culture within the home. There were regular meetings and people and staff were supported to make suggestions about how to make improvements.