Collyhurst is a residential care home, providing personal care and accommodation to 34 older people. There are 30 bedrooms in the main house spread over 3 floors. The basement and ground floor both have a dining area and a kitchenette. The communal lounge is located on the ground floor. There are a further four bedrooms in a bungalow annex. At the time of our inspection, the provider was making changes to the building to link the main building and bungalow annex. Twenty six people lived at the home when we inspected.
People’s experience of using this service and what we found
Risk’s to people’s health had been identified, but records did not always show how these risks had been assessed and mitigated.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.
The registered manager and provider did not fully understood their responsibilities under the Mental Capacity Act. Where a person’s capacity to make a decision had been questioned, capacity assessments were incomplete and not decision specific.
Staff had not always received training to support people with specific health conditions such as epilepsy and diabetes. Some mandatory training was out of date.
Systems and processes had not been effective in identifying the shortfalls found during our inspection.
The home was generally clean but there was a strong odour in the communal lounge. Staff followed good infection control practices and used personal protective equipment (PPE) appropriately.
People and relatives told us they felt safe at Collyhurst. Staff understood their responsibilities to protect people from avoidable harm.
People's health and emotional needs were assessed before they moved to Collyhurst to identify what support they needed.
There were enough staff to keep people safe. Assessed staffing levels had been maintained and staff were recruited safely.
People had access to the healthcare they required and were supported to access healthcare services, such as their GP, district nurse and optician. People received their medicines as per their individual prescriptions.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection (and update)
The last rating for this service was requires improvement (published 25 June 2019) and there was a breach of regulation 17 Good Governance. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made, and the provider was still in breach of regulations.
The service remains rated requires improvement. This service has been now been rated requires improvement for the last three consecutive inspections.
Why we inspected
The inspection was prompted in part due to concerns received about poor personal hygiene, staff not responding quickly enough to assist people and infection control practices. In addition, as a breach of legal requirements was found at the last inspection we undertook this focused inspection to review the key questions of safe, effective and well-led only. We also checked they had followed their action plan and to confirm they now met legal requirements.
We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.
We have found evidence that the provider needs to make improvements. Please see the safe, effective and well-led sections of this full report. As a result, the overall rating for the service has remained the same. This is based on the findings at this inspection.
You can see what action we have asked the provider to take at the end of this full report.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Collyhurst on our website at www.cqc.org.uk.
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service to keep people safe and to hold providers to account where it is necessary for us to do so.
We have identified breaches in relation to safe care and treatment and good governance at this inspection.
Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.
We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.