About the service: Combs Court is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. This service does not provide nursing care. Combs Court can accommodate up to 29 people, there were 22 people using the service on the day of our inspection. The service comprises of four houses on one site and one house is further subdivided into individual flats. There are also two separate self-contained flats which were not occupied at the time of our inspection.

At the time of registration the service was not developed in line with the principles of and values of Registering the Right Support however the service is working towards these principles. These values include choice, promotion of independence and inclusion.

People’s experience of using this service:

¿ At our last inspection of 31 January 2018, the service was rated requires improvement overall. The key questions for safe and caring were rated good and the key questions for effective, responsive and well-led were rated as requires improvement.

¿ As that was the second time we had rated the service as requires improvement we met with representatives of the organisation in order for them to tell us how they planned to improve the service. At this inspection we found improvements had been made and the service is now rated good overall and in all key questions.

¿ People told us that they were content with the service. One person commented, “There are lots of things to do here.” A relative told us, “Things have improved because the staff have more time to spend with [my relative].”

¿ The service had systems in place to keep people safe.

¿ Risks to people had been assessed and plans had been written to mitigate the risks.

¿ The registered manager used a dependency tool to determine the hours required to support people and then arranged the staffing rota to ensure there were sufficient staff on duty.

¿ People’s medicines were managed safely.

¿ Infection control procedures were in place to reduce from the risks of cross infection.

¿ People had access to health professionals when needed. People were supported to maintain a healthy diet.

¿ People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible.

¿ Staff supported people to cook some meals for themselves and to go shopping for food.

¿ People’s privacy, independence and dignity was respected.

¿ People’s needs were assessed prior to them coming to live at Combs Court for the purpose that the staff could meet their needs and their care plan was reviewed monthly or more frequently should the need arise.

¿ People were listened to in relation to their choices about how they wanted to be cared for.

¿ There was a complaints procedure in place and people’s complaints were addressed. People were asked for their views about the service and these were valued and listened to.

¿ People’s individual interests had been recorded and the service had increased meaningful activities to support people to achieve their individual interests.

¿ There was a service governance process in place designed to monitor and improve the service.

Rating at last inspection: At our last inspection on 31 January 2018 the service was rated requires improvement overall and the report was published on 16 April 2018.

Why we inspected: This inspection took place as part of our planned programme of inspections, based on the rating of requires improvement made at our last inspection.

Follow up: We will continue to monitor this service according to our inspection schedule.

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

This inspection was carried out on 31 January 2018, and was an unannounced inspection.

Combs Court provides accommodation and personal care for up to 30 people who have a learning disability or who are on the autistic spectrum. There were 27 people living at the service at the time of the inspection. Combs Court is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Combs Court comprises of a number of accommodations on one site with the largest being for seven people while other people live and are supported in single person accommodation.

At the last Care Quality Commission (CQC) inspection on 23 August 2016, the service was rated Good in the key questions Effective and Caring, and the rating for Safe, Responsive and Well Led key questions were Requires Improvement with an overall rating of Requires Improvement.

At this inspection we found the service still Required Improvement. Although there had been some improvements new concerns were identified and we have now also rated the Effective question as Requires Improvement but have rated the Safe question as good.

The registered manager had left the service in the Autumn of 2017 and the new manager had commenced in December 2017 but had left a few weeks later before they had registered with the CQC. At the time of the inspection management cover was being provided by a registered manager on a part-time basis from another service and was supported by a deputy manager full-time.

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 gave us mostly positive feedback about the service they received. People told us they felt safe and well looked after. However most of the people who sought support with their social needs were disappointed with the reduction in outings and closure of the communal centre at the service. The relatives we spoke with during our visit were of the same opinion.

Assessments of support needs were not always accurate but the covering manager had increased staff support to focus upon keeping people safe.

Care plans had been written in a person-centred style but needs identified were not always met regarding social care needs. People were supported to raise concerns.

The staff demonstrated a clear understanding of the actions they would take if they suspected or witnessed any concerns about people’s safety. Risks were assessed and management plans were in place to minimise the risk to people’s safety.

There were enough staff on duty to keep people safe made up of regular staff, agency staff and staff working overtime. However particularly due to the lack of staff that held a driving licence and the closure of the communal resource centre on site people’s social needs and opportunities to pursue interests and hobbies were not always achieved.

Staff had received infection control training and used this information for the storage of food and cleanliness of the service.

The senior staff learned from incidents or accidents within the service and made the necessary improvements. They shared this information with the staff through supervision and staff meetings.

Staff were provided with training appropriate to the various needs of the people living at the service.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. People were provided with a healthy and well balanced diet and were encouraged to take part in the preparation of meals.

Other professionals worked with staff so that people had access

The inspection took place on 14 August and 7 September 2016 and was unannounced. The service provides accommodation and personal care for up to 30 people who have a learning disability or who are on the autistic spectrum. Due to changes and upgrading the service is proposing to reduce its numbers to 29 in the near future. The service is divided up into units called The Beeches, Laurel and Willows plus bungalows and an activity centre which are based around a court yard with gardens. There were 25 people using the service on the day of our inspection. One unit was undergoing refurbishment so that the accommodation would be more suitable for people with more independence.

The service did not have a registered manager in post as they registered manager had left the organisation a few weeks prior to our inspection. The service was being managed by an experienced manager from the organisation and they informed us they would be seeking to become the registered manager.

A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.

At our last inspection in March 2014 the service was compliant with the regulations inspected.

People were protected from the risk of abuse as staff had attended training to ensure they had good understanding of their roles and responsibilities if they suspected abuse was happening. The manager had shared information with the local authority when needed to ensure people were safeguarded as far as possible.

People were supported by a sufficient numbers of suitably skilled and knowledgeable staff. The provider had ensured appropriate recruitment checks were carried out on staff before they started work. Staff had the skills and knowledge to provide care and support in ways that people preferred.

The provider had systems in place to manage medicines and people were supported to take their prescribed medicines safely. Although the recording of the ‘as required medicine’ could be better as there were gaps in the medicine chart because staff had not always followed the guidance on the medicine chart. However all medicines were accounted for so we could be confident that when staff had signed to say medicine had been administered this was the case.

The manager, the management team and the staff were passionate about providing people with support that would enable them to lead lives of their choice. We saw evidence of how the staff were supporting people to develop their own independence and use the service as a stepping stone to move on to other accommodation. The service provided staff with support through meetings, annual appraisals and supervision. The manager was embarking upon providing additional support and training for the supervisors.

The service was meeting the requirements of the Deprivation of Liberty Safeguards (DoLS). Appropriate mental capacity assessments and best interest decisions had been undertaken by relevant professionals. This ensured that the decision was taken in accordance with the Mental Capacity Act (MCA) 2005, DoLS and associated Codes of Practice. The Act, Safeguards and Codes of Practice are in place to protect the rights of adults by ensuring that if there is a need for restrictions on their freedom and liberty these are assessed and decided by appropriately trained professionals. People at the service were subject to the Deprivation of Liberty Safeguards (DoLS). Staff had been trained and had a good understanding of the requirements of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.

Positive and caring relationships had been developed between people and staff. Staff responded to people’s needs in a compassionate and caring manner. People were supported to make day to day dec

We spoke with four people who used the service. We also spoke with the manager, deputy manager and two members of staff. We looked at five people's care records, and policies regarding fire regulation and testing the temperature of hot water.

We considered our inspection findings to answer questions we always ask; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

This is a summary of what we found;

Is the service safe?

When we arrived at the service we were greeted by the manager and deputy manager. We were asked for our identification and asked us to sign in the visitor's book. This meant that the appropriate actions were taken to ensure that the people who used the service were protected from others who did not have the right to access their home.

People told us they felt safe living in the service and that they would speak with the staff if they had concerns.

We reviewed staffing records regarding the Mental Capacity Act (MCA) 2005 in relation to Deprivation of Liberty Safeguards (DoL’S) and saw this training was up to date. The CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. The manager, deputy manager and member of staff spoken with were able to demonstrate a knowledge and understanding of the MCA and DoL’S. The manager informed and showed to us the DoL’S applications that the service had made. The service had followed correct the relevant policies and procedures.

People told us that the staff were available when they needed them to help and support them. One person told us about a hospital appointment and they felt safe that the staff were aware of this and would attend the appointment with them.

Is the service effective?

People's care records showed that care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. The care plans were indexed for ease of reading and finding information. The records were reviewed monthly and updated as required. This meant that staff provided information that was up to date about how people's needs were met.

Is the service caring?

We saw that the staff interacted with people who used the service in a caring, respectful and professional manner. One person showed to us the garden where they were growing vegetables. They told us. “The staff have shown me how to do this.” There were arrangements in place for the staff to work with other organisations to support people to follow their life-style choices and provide care.

Is the service responsive?

The service arranged and supported people to go shopping to purchase the food they liked to eat. People who used the service were provided with the opportunity to participate in activities which interested them. People's choices were taken into account and listened to as each person had an individualised program of activities to pursue.

One person told us that they knew how to make a complaint if they were unhappy. We saw that the service had involved advocates appropriately to support people and had arranged for people who used the service to learn skills to help them communicate with people. During our inspection we met a visiting professional Speech and Language Therapist who was working with a person regarding specific needs.

People's care records showed that where concerns about their wellbeing had been identified, the staff had taken appropriate action to ensure that people were provided with the support they needed.

Is the service well-led?

The service worked well with other agencies and services to make sure people received their care in a joined up way. We saw the process used to ensure there were sufficient staff on duty to meet the assessed needs of people who used the service.

The registered manager had developed a training program for staff designed to develop their skills to provide care to the people who used the service. There was a quality assurance system in place which included a complaints policy and procedure and robust recruitment arrangements.

We spoke with the deputy manager, a team leader and another member of staff and two people who used the service. We saw the service had undergone a major refurbishment with which the people who used the service had been involved. One person told us, “I enjoyed the florist course yesterday.” The service had arranged a number of activities which were provided at the location and some people attended courses at various places away from the service.

The service had responded to our previous inspection visit of January 25th 2013, although there were no compliance actions the service had increased the space available and improved the environment for the people who used the service in their respective day rooms and dining areas. This was because the service had adapted the accommodation to store in understair locations the medication trolleys.

We found there were appropriate safeguarding procedures in place and also a robust complaints policy and procedure. The service had also involved and respected people that used the service. There was a safe recruitment process and supported staff with supervision and training. However we found some of the care plans were unclear and difficult to understand as they repeated themselves under different headings and some had not been signed by the person who used the service. During the inspection we learnt that three people had gone on holiday supported by staff. We saw staff caring for people by supporting them with their dietary needs.

This was a follow up inspection to look at the compliance action we had made at our inspection on 2 December 2012. At this return visit we found that matters had improved. In January 2013 we received an action plan stating what action would be taken by the provider to reach compliance. At this inspection we found that actions had been put into place.

We found that suitable arrangements had been put in place for the storage and recording of medication. This meant that people were protected against the associated risks of medicines management.

This inspection was conducted on a Sunday and we found most people at the service. We met and spoke with ten people who live at the service and spoke with five staff who were on duty.

We looked at matters relating to consent and found that the staff at the service had a good knowledge and understanding and used this in their practice to support people with decisions and making choices. We looked at care plans and how people were supported and found that in the majority of cases peoples needs were assessed and their needs were met. People were keen to tell us that they liked living at this service and that they had good relations with staff who supported them. We raised at inspection and in this report that the service could better plan and assess the needs for the aging people who use this service.

We looked at staffing levels within the service and found that these were sufficient to meet people’s needs. We examined how medication was managed within the service and have made a compliance action because people were not entirely protected against the risks associated with medicines.

We met and spoke with eight people who told or indicated to us they were happy at Combs Court. We observed that people were given opportunities and choices throughout the day with several people attending regular activities based within the community, or at the day service developed upon site. We were told of the many varied experiences people had in previous months that were developed through the day centre. All were based on individual choice and involvement. One person had been out playing pool at a local venue another person went into the local town with their befriender. People who lived at Combs Court looked smart and well cared for. One person we spoke with was particularly looking forward to a mystery trip out that afternoon planned with their one to one supporter and a relative. Generally people we saw looked happy and contented.

Two people we spoke with using the service told us that they liked the staff. “We love living here, the staff are alright they are good staff”. We observed that relationships between staff and people were friendly, warm and appropriate.