Archived: Coleridge House

Updated 28 June 2016

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 was 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 inspection took place on 10 and 17 May 2016 and was unannounced. On the first day of the inspection, the team consisted of one inspector and one expert-by-experience. 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 day two of the inspection, there was one inspector.

Before the inspection visit, 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. As part of our planning we reviewed the information

in the PIR.

We reviewed the information we held about the service, which included notifications. Notifications are changes, events or incidents that the registered provider must inform CQC about.

We spoke with four people using the service and seven relatives across the three units. We spoke with the manager, three assistant managers and four care staff.

We looked at the records of three people, which included their risk assessments and care plans. We reviewed two staff employment records and other records which related to the management of the service such as quality assurance, staff training records and policies and procedures.

We observed how people were supported during their lunch and activities. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

Updated 28 June 2016

This inspection took place on 10 & 17 May 2016 and was unannounced. At our previous inspection on 10 February 2014 the provider was not meeting all the regulations that we checked. We asked the provider to make improvements around staffing, as people were not always supervised appropriately. At this inspection we found that improvements had been made.

Coleridge House provides residential care for up to 40 older people, living with dementia and or a physical disability, or sensory impairment. There are bedrooms on the ground and first floors. It is split into three units each with its own lounge and dining area. The service has a high dependency unit (Chestnut), which provides care for people living with dementia and two low dependency units (Maple and Willow). There were 32 people living at the service at the time of our inspection.

There was no active registered manager in post. There was a manager recently appointed at the service who was covering this position. The provider confirmed that the manger would be applying to become the registered manager. The home is required to have a registered manager in post. 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 and associated Regulations about how the service is run.

People we spoke with said they felt safe at Coleridge House. The provider had taken steps to protect people from harm. Staff had an understanding of potential abuse and their responsibility in keeping people safe.

Safe systems were in place to manage people’s medicines and medicines were stored safely. Risk assessments and care plans were kept up to date. Staff had the relevant information on how to minimise identified risks to ensure people were supported in a safe way.

Staffing levels were monitored to ensure people’s needs were met. The provider’s recruitment procedures ensured suitable staff were employed to work with people who used the service. Staff received training to meet the needs of people living at the service and received supervision, to support and develop their skills.

The manager understood their responsibility to comply with the requirements of the Mental Capacity Act 2005. However mental capacity assessments had not been completed. Deprivation of Liberty Safeguards (DoLS) applications had been made to ensure people’s rights were protected. Staff gained people’s verbal consent before supporting them with any care tasks and promoted people to make decisions.

People were not always given choices with regard to food and drink preferences and appropriate support when needed. People were supported to maintain good health and to access health care services as required.

Staff were caring in their approach and had a good understanding of people’s likes, dislikes and preferences. Staff supported people to maintain their dignity. People were supported to maintain and develop their social interests. People felt confident that they could raise any concerns with the managers.

There were processes in place for people and their relatives to express their views and opinions about the service provided. There were systems in place to monitor the quality of the service to enable the manager and provider to drive improvement.

Staff felt supported by the management team. The leadership and management of the service and its governance systems ensured consistency in the care being provided.