Archived: Colebrook Manor

Updated 29 December 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.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection team was made up of three inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone.

Service and service type

Colebrook Manor 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. Colebrook Manor is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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. At the time of our inspection there was a registered manager in post.

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. 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.

During the inspection

We spent time with and spoke with nine people living at the service and one relative. We spoke with five members of staff including the registered manager. To help us assess and understand how people's care needs were being met we reviewed 13people's care records.

We also reviewed a number of records relating to the running of the service. These included staff recruitment and training records, medicine records and records associated with the provider's quality assurance systems. We looked at training data, policies and quality assurance records.

Updated 29 December 2022

About the service

Colebrook Manor provides nursing care and support for older people. The service is registered to accommodate 49 people in one adapted building. The service supports people who are living with dementia, nursing or residential care needs. At the time of our inspection there were 22 people living at the service.

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

The provider had made some improvements in the service. For example, staffing arrangements. However, the provider had failed to act upon known areas of concern to improve the quality of care and safety for people at Colebrook Manor. This had exposed people to on-going poor care and risk of avoidable harm.

There were ineffective systems in place to assess, monitor and improve the quality and safety of the service. People were not protected from the spread of infection. The provider was adhering to government guidelines for working safely in care homes during the COVID- 19 pandemic. However people were not always protected from the risk of infection, because the premises were not always clean and well maintained.

Medicines were managed safely, and 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. Staff knew how to identify and report any concerns. There were sufficient staff deployed to meet people's needs and staff recruitment was on-going.

People told us staff were caring. Staff did all they could to promote independence and we saw examples of this taking place.

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 inadequate (published 02 November 2021)

The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found some improvements had been made however we found the provider remained in breach of regulations.

The last rating for this service was inadequate. The service is now rated requires improvement. This service has not achieved a rating of good for the last two consecutive inspections. This service has been in Special Measures since 02 November 2021.

During this inspection the provider demonstrated some improvements have been made. However, the service is still rated as inadequate in the well-led key question. Therefore, this service is still in Special Measures.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

We undertook a focused inspection to review the key questions of safe, effective and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from Inadequate to Requires improvement. This is based on the findings at this inspection.

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.

We have found evidence that the provider needs to make improvements. Please see the safe, effective and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

Enforcement

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 breaches in relation to safe care and treatment, leadership and governance and person centred care.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will continue to work with the local authority to ensure people's safety. The provider has taken the decision to deregister this service.