Collyhurst

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.