Collyhurst

Updated 15 April 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

Inspection team

The inspection was carried out by two inspectors.

Service and service type

Collyhurst is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Collyhurst is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had two managers registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service such as Healthwatch. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with seven people who used the service and two relatives about their experience of the care provided. We spoke with seven members of staff that included both registered managers’, a senior care worker, two care worker, the activities co-ordinator and a domestic staff member. We reviewed a range of records. This included three people’s care records and two people's medicine records. A variety of records relating to the management of the service, including quality assurance audits and training records were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found.

Updated 15 April 2022

About the service

Collyhurst is a residential care home registered to provide 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. Twenty-nine people lived at the home when we inspected.

People’s experience of using this service and what we found

Risks to people's health had been identified. However, records did not always show how these risks had been assessed and mitigated. Staff recorded accidents and incidents in people's individual care plans. However, there was very limited information about investigations carried out to identify the cause, or actions taken to mitigate future incidents from happening again.

Improvements were required to ensure safe medicines practices. Errors had occurred due to failures in the systems to support safe medicines practices.

Some areas of the home did not promote good infection control processes. For example, the main downstairs bathroom’s extractor fan was extremely dirty and the skirting boards were hanging away from the wall and could not be cleaned properly. Some areas required de-cluttering.

Systems and processes were in place to monitor and improve the quality of care provided but they were not effective in identifying the areas of improvement we found during our visit. For example, records did not always contain enough information on how to reduce risks, fluid charts were not being reviewed, medication errors and some infection control risks within the environment had not been identified.

Where people’s capacity to make decision was questioned, mental capacity assessments had been completed. However, these required more detail to evidence how decisions about a person's capacity had been made.

People and relatives provided mixed feedback about the quality of food. The mealtime experience required some improvements. Drinks were not offered to people until after the meals had been served and adding gravy to a meal was assumed and without the person’s involvement.

People told us there were enough staff to meet their needs. Staff told us staffing levels enabled them to look after people safely and records confirmed that assessed staffing levels were maintained. The provider was facilitating visitors in line with government guidance.

People told us staff were caring and treated them with kindness and compassion. Relatives were complimentary about the standards of care provided at the home. People chose how their care was provided and were encouraged to express their views.

People received personalised care and told us staff were responsive to their individual needs. There was a calm atmosphere within the home and people told us they felt safe. Staff understood their safeguarding responsibilities.

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 supported this practice.

People told us staff were responsive to their health needs. The registered managers worked effectively with external health and social care professionals such as the GP who conducted a virtual weekly ward round

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

This is the first inspection under the newly registered provider. The last rating for the service under the previous provider was requires improvement, published on 27 November 2021. The registered manager remained the same.

Why we inspected

We undertook this inspection to check whether improvements identified at our last inspection, under the previous provider, had been made. 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. This included checking the provider was meeting COVID-19 vaccination requirements.

Enforcement and Recommendations

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 and will take further action if needed.

We have identified a breach in relation to governance at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from 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 continue to monitor information we receive about the service, which will help inform when we next inspect.