About the service:

Combe House is a residential care home that provides support and personal care for up to seven adults with learning disabilities. The people who live at Combe House have significant support needs because of their disabilities, communication impairments, mental health and autism.

People’s experience of using this service:

Most people living at Combe House were not able to tell us verbally about the care they received. Most people had complex needs and some needed one to one support. We observed that people were cared for in a kind way by the staff and they were kept occupied during the day. Some people had the opportunity to go out to the park and for lunch together.

However, relatives expressed concern about the management of people’s care, their lack of involvement and communication with the home. Some concerns were about the limited range of individual activities and stimulation for people. At the inspection we found evidence that the service needed to improve in several areas.

There had been some incidents where there had not been sufficient guidance in place to manage risk due to people’s anxiety and behaviour. We saw this had begun to be addressed by the time of inspection, but these strategies and support had yet to be fully embedded with staff.

The staff team was small, and some worked long hours consistently during the week. It was not clear how staffing levels and deployment was assessed, based on people's needs and individual requirements. There were gaps in staff training which needed to be urgently addressed. We also had concerns about the safety of staffing levels at night and the ability of the service to deal with an emergency.

People’s living environment was not as clean as it should have been, and some parts of the home needed to be better maintained and improved.

Some people were unable to give their consent or make decisions about their care and supervision. At the inspection, the service was not acting within the requirements of the Mental Capacity Act 2005 by demonstrating how and why decisions were made in a person’s best interests.

We considered whether the service was meeting the standards that underpin Registering the Right Support, national best practice guidance for people living with a learning disability. These values include choice, promotion of independence and inclusion for people. There were incidences where the language and treatment used was not always respectful of people as adults which is not in line with the values and standards for people with learning disabilities.

There was a lack of management presence and oversight which we judged had an impact on the overall quality of care. We were unable to find up to date information, such as on complaints and staff training and organisation could be improved. Although some service audits had been undertaken, these were not robust or comprehensive. Concerns we found not been identified. Relatives views were not recorded or acted on. A safeguarding investigation was underway, and the provider had not notified the CQC in line with legal requirements. This was sent in once the inspection had happened.

The registered manager and provider sent us further information after the inspection in response to our feedback. Since the inspection, the provider has agreed to increase management cover and complete more robust checks at the home.

We identified six breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and one breach of the Care Quality Commission (Registration) Regulations 2009. We also made one recommendation about staffing.

Details of action we have asked the provider to take can be found at the end of this report. The provider started to take action immediately following the inspection. They have communicated their intention to improve and to meet with families to address their specific concerns.

Rating at last inspection:

The last inspection report was publish

This inspection took place on 31 August 2016 and was unannounced. We returned to the home on 9 September to complete our inspection.

Combe House is a home providing accommodation and personal care for up to seven adults with learning disabilities. It is situated in Horsell, Woking. At the time of our inspection there were no vacancies. The people who lived at Combe House had significant support needs because of their learning disabilities such as physical and communication impairments, autistic spectrum conditions and behaviours considered to be challenging.

There was 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 2008 and associated Regulations about how the service is run.

A family member told us that they felt that people who lived at the home were safe. We saw that people were comfortable and familiar with the staff supporting them.

People who lived at the home were protected from the risk of abuse. Staff members had received training in safeguarding, and were able to demonstrate their understanding of what this meant for the people they were supporting. They were also knowledgeable about their role in ensuring that people were safe and that concerns were reported appropriately.

Medicines were well managed by the home. People’s medicines were managed and given to them appropriately. Records of medicines were well maintained.

We saw that staff at the service supported people in a caring and respectful way, and responded promptly to meet their needs and requests. There were enough staff members on duty to meet the needs of the people using the service.

Staff members received regular relevant training and were knowledgeable about their roles and responsibilities and the needs of the people whom they supported. Appropriate checks took place as part of the recruitment process to ensure that staff members were suitable for the work that they would be undertaking. All staff members received regular supervision from a manager, and those whom we spoke with told us that they felt well supported.

The home was meeting the requirements of The Mental Capacity Act 2005 (MCA). Information about capacity was included in people’s care plans. Applications for Deprivation of Liberty Safeguards (DoLS) authorisations had been made to the relevant local authority to ensure that people who were unable to make decisions were not inappropriately restricted. Staff members had received training in MCA and DoLS, and those we spoke with were able to describe their roles and responsibilities in relation to supporting people who lacked capacity to make decisions.

People’s nutritional needs were well met. Meals provided were varied and met guidance provided in people’s care plans. Alternatives were offered where required, and drinks and snacks were offered to people throughout the day.

Care plans and risk assessments were person centred and provided detailed guidance for staff around meeting people’s needs. Systems for supporting and monitoring people’s needs and behaviours were effectively used and monitored.

A range of activities for people to participate in throughout the week was provided by the home. Staff members supported people to participate in these activities. People’s cultural, religious and relationship needs were supported by the service and detailed information about these was contained in people’s care plans.

The service had a complaints procedure. A family member told us that they knew how to make a complaint but did not have any complaints about the home.

The care documentation that we saw showed that people’s health needs were regularly reviewed. Staff members liaised with health professionals to ensure that people received the support that they needed.

We saw that