Coombe Dingle Nursing Home provides care and accommodation for up to 42 older people living with dementia. The registered provider had recently changed all double rooms to single rooms and submitted an application to CQC to reduce the maximum number of people to 35. On the day of our inspection 26 people were living in the home.

This was an unannounced inspection that took place on 14 June 2017.

The home had a registered manager. 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. The registered manager assisted us with our inspection on the day.

We carried out an inspection to this home in April 2016 where we identified four breaches of the HSCA (Regulated Activities) Regulations 2014. This included a lack of safe care and treatment, a failure to following the legal requirements in relation to the Mental Capacity Act (2005), a failure to always treat people with dignity and respect and a lack of good governance within the home. Following that inspection the registered provider submitted an action plan to tell us how they planned to address our concerns. We undertook this fully comprehensive inspection to check that the provider had taken appropriate action in line with their action plan. We found there had been significant improvement in all areas.

People were cared for by a sufficient number of staff. People’s needs were responded to in line with their care plan and in a prompt manner. Staff demonstrated a caring attitude towards people. One that showed people respect and made them to feel as though they mattered. Staff were patient with people and took time with people to allow them to express their needs.

Where risks had been identified for people or they had experienced accidents or incidents staff took appropriate action. The registered manager monitored and audited all accidents and incidents and ensure staff followed these up. People’s medicines were managed appropriately and when people required the input of a healthcare professional this was arranged.

Staff had a good understanding of what they should do if they had any concerns about how people were being cared for and the provider had robust recruitment processes in place to help ensure that only appropriate staff were employed in the home. In the event of an emergency people’s care would continue with the least disruption possible as the registered provider had reciprocal arrangements with local providers. Staff helped ensure that people lived in a safe environment that was well maintained. We observed improvements in the décor and maintenance of the home compared to our previous inspections.

Where people had specific dietary requirements these were recognised by staff. People were shown visual choices of food to aid their decision making and where people required support to eat this was provided for them. Activities took place within the home and staff were seen engaging with people. The registered manager told us that they were currently training a staff member to lead on activities in order to offer more variety to people.

People were cared for by staff who felt supported and valued by the registered manager. They had been given access to all the necessary training to allow them to carry out their roles competently. There were plans for additional training underway to help ensure staff had a thorough knowledge of caring for people living with dementia.

People’s care plans were detailed and contained information for staff in order that they could provide people with appropriate care. People and relative’s told us they felt they could speak to staff or management if they were unhappy about any aspect of their care. A wide range of quality assurance audits and checks were in plac

Coombe Dingle Nursing Home provides accommodation and nursing care for up to 42 people. It is a large building set over three floors. There is lift access to the first and second floors. At the time of this inspection there were 31 people living at the home.

This was an unannounced inspection which took place on 19 April 2016. At our previous inspection in September 2015 we found a number of breaches of legal requirements. As result the service was rated Inadequate overall and the provider was placed into Special Measures by CQC. We issued one Warning Notice which required the provider to take immediate action in relation to medicines. We also took enforcement action and changed their registration to restrict admissions until such time as significant improvements had been made and sustained within the home. We have carried out this further fully comprehensive inspection to see if the provider took action to address our concerns. We had received an action plan from the provider following our previous inspection and we reviewed progress against that action plan during this inspection.

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 and associated Regulations about how the service is run. The registered manager assisted us with our inspection on the day.

We saw some staff acted in a way that was not always appropriate or respectful. People has access to external healthcare professionals should they need it and most staff treated people with kind care and attention. However, we observed some staff did not always demonstrate this routinely.

Good medicines management processes were not always followed by staff although people did receive the medicines they required when they needed them. Care records and individual risk assessments for people were not always completed for people.

Although the provider had worked hard to improve the premises work had not yet been completed, particularly in relation to installing a sink in the laundry room. Staff still had to wash their hands in a separate room which could pose an infection control risk.

Care plans were more accurate that we had previously found however, we still found some inconsistencies in the information they contained. We found more activities were being provided to people and staff told us they felt there was more going on in the home. However, further improvement is required to ensure activities are individualised and meaningful.

Staff did not always follow the legal requirements in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. Accidents and incidents were recorded, however incidents were not always reported to CQC when they should be.

People with specific dietary requirements were now known to the chef. Following our inspection the provider has told us they have introduced different ways of giving people living with dementia a way to help them choose their meal.

Quality assurance checks were carried out by staff. Most actions arising from these audits had been completed, but there was further work required.

Staff interacted with people and listened to them and the atmosphere in the home had improved from our last inspection. Staff told us they were working better as a team and much happier working at Coombe Dingle Nursing Home.

There were a sufficient number of staff to meet people’s needs and people did not have to wait to be supported. The provider carried out suitable recruitment processes to help ensure they only employed staff suitable to work in the home.

Staff had access to regular training as well as the opportunity to meet with their line manager on a regular basis to discuss their work. Staff knew how to report any concerns they had in relation to safeguardi

Coombe Dingle Nursing Home provides nursing care and treatment for up to 42 people, most of whom are living with dementia. The home is divided across three floors. On the day of our inspection 31 people were living in the home.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider. The registered manager was present during our inspection.

We carried out this inspection on 22 September 2015. This was to follow up on three breaches in regulation from our inspection in January 2015. As there had been a period of time between inspections we carried out a fully comprehensive inspection on this occasion.

People lived in an environment that was not well maintained or clean. Staff did not follow suitable infection control procedures and the provider had not made the improvements required of them from the last inspection.

Safe medicines management procedures were not always followed by staff and we found this was a continued breach of regulation from our last inspection. People had access to external health services however we found people may not always be provided with responsive care by staff.

Staff had not followed legal requirements of the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards (DoLS) in respect of restrictions or decisions made on behalf of people.

Up to date, contemporaneous and accurate records for people were not held which meant new or agency staff may not be working to the latest information. Staff had not taken the time to read care plans or information about people in order to get to know them to ensure they provided appropriate care and support.

Quality assurance checks were carried out by staff as well as the provider and feedback was sought from relatives. However, we found these checks had not identified areas that required improvement and the provider had not acted on areas we had identified at our previous inspection in relation to the ensuring they were providing a high quality, safe service.

Staff provided activities for people, however people who spent a lot of time in their room did not receive much social interaction from staff at times. Staff were not observed as always being proactive in engaging with people. Staff did not always treat people as though they mattered or with respect and people’s privacy was not always upheld.

People were not offered a choice of meals in a way they would be able to understand and people who required a pureed food did not get a choice. Although people’s dietary requirements were known by staff some information was contradictory or not provided to the chef in a way they would be able to easily identify these people.

Staff were not provided with training specific to the needs of people. Despite staff telling us no-one living in the home had capacity we found staff did not have a good understand of dementia and had not been given access to training.

Complaints procedures were in place and we saw most complaints had been resolved. One complaint was on-going as the complainant was not happy with the initial response from the registered manager.

There were a sufficient number of staff deployed in the home. We did not see people wait to be assisted and observed there was always someone around for people who were sitting in the lounge area.

We did observe some staff displaying kind, compassionate care to people and it was clear staff knew visitors to the home well. A complaints procedure was available for people or relatives if they had any concerns.

Staff had identified risks for people to demonstrate people were safe living at Coombe Dingle and we saw evidence staff had received manual handling training since our last inspection. Staff demonstrated good practices when lifting and moving people.

Staff were aware of their responsibilities to safeguard people from abuse and were able to tell us what they would do in such an event. And in the case of an emergency people’s care would not be compromised because the provider had contingency plans and suitable arrangements if people needed to be evacuated.

Staff felt supported by the registered manager. They had the opportunity to meet with their individual line managers on a regular basis and contribute towards the running of the home through staff meetings. Appropriate checks were carried out to help ensure only suitable staff worked in the home.

During the inspection we found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

The overall rating for this service is ‘Inadequate’ and the service has therefore been placed in ‘Special measures’. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent

enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Coombe Dingle Nursing Home provides nursing, personal care and accommodation for up to 42 older people, some who are living with dementia. Others have an acquired brain injury or who have behaviour which may cause them to harm themselves or others. The home is over three floors, has a lift for easy access for people. There is a dining and two lounge areas on the ground floor, together with an activities room and a level garden to the rear of the building. On the day of our inspection 34 people were living in the home.

This inspection took place on 16 January 2015 and was unannounced.

The home is run by a registered manager, who was present on the day of the inspection. 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 told us they felt safe and staff had written information about risks to people and how to manage these. People were supported to take risks within a controlled environment. For example, using the stairs rather than the lift when they wished. However, staff used incorrect manual handling procedures when they supported people to get out of their chairs, which placed the person and staff at risk of injury.

Medicines were not managed effectively and staff did not follow correct and appropriate procedures in relation to medicines.

Staff had received training in safeguarding adults and were able to evidence to us they knew the procedures to follow should they have any concerns. Information was available to people as well as their relatives.

Care was provided to people by staff who were trained to carry out their role. Some people said they would like to see more staff on duty and, particularly in the morning, staff were rushed. However, people did not have to wait to be assisted. One person said, “When I call for help they (staff) come.” Staff were provided with specific knowledge to provide effective care. For example, staff had undertaken training in dementia, challenging behaviour and end of life.

The registered manager explained their understanding of their responsibilities and processes of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). There was currently no one living at the service who was restricted in any way. The registered manager explained they were in the process of ensuring mental capacity assessments were in place for people where appropriate. For example, in the event a person had bed rails.

People were provided with freshly cooked meals and facilities were available for staff to make or offer people snacks at any time during the day or night. People felt the food was good.

Staff ensured people had access to healthcare professionals when needed. For example, the doctor or optician. The GP visited the home each week and met with people.

Staff had developed relationships with people. However, people were not always provided with the dignity and respect they should expect.

Care plans were individualised and contained information to guide staff on how someone wished to be cared for. Care plans were reviewed regularly however we found some care plans did not contain individualised information about the person such as their likes/dislikes, interests or wishes in relation to activities. People had personalised care responsive to their needs. For example, one person had one to one care from staff. We heard of the ways in which staff supported and enabled people to maintain their independence and take part in various activities to reduce the risk of social isolation.

Complaint procedures were accessible to people. We read the provider had responded to complaints in a timely manner.

The provider asked relatives for their views on the service and used the feedback to develop an action plan of improvements. The provider was working with a trained healthcare professional to improve the environment and make it more appropriate for people who were living with dementia.

The registered manager was involved in the day to day running of the home. This was supported by our observations and staff comments. One staff member told us, “The (registered) manager is always around.” However, we felt the amount of time they spent out on the floor may have had an impact on their managerial duties and responsibilities.

We saw evidence of regular quality assurance checks carried out by staff to help ensure the environment was a safe place for people to live.

During the inspection we found some breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of the report.

During our inspection in February 2014, we found the provider had not met the regulations in relation to the safety and suitability of the premises.

We carried out this follow up inspection to check that the provider had taken the necessary action to ensure the premises were suitable for the people who lived there.

We found the provider had made appropriate alterations in line with our recommendations which meant that people who used the service were protected against the risks of unsafe or unsuitable premises.

All the relatives and befrienders we spoke to except one were very positive about the home and told us they were kept informed and involved, felt the staff were good and had a pleasant and friendly attitude and that their relative or friend was well cared for.

Two relatives pointed out where a staff member put their arm around a person that was confused to reassure them and they told us that demonstrated the difference they found at this home with caring and companionate staff.

Only one common negative theme arose with people we spoke to, which was a concern about the staffing levels in the new lounge on the first floor. We raised this with the providers and manager who agreed to reallocate staffing resources to cover this new area.

The last inspection found shortfalls in 5 out of 7 areas looked at and set compliance actions. The areas were shortfalls were found were, care planning, infection control, the environment, staff recruitment and monitoring of the service.

At this inspection we reviewed the actions the provider had taken in response to the compliance actions and found that in 4 out of the 5 areas the provider had fully met the compliance actions, and in the final area, the environment, the provider had made progress but more was required.

The last inspection report identified shortfalls under outcome 4 (regulation 9) with peoples risk assessments and turning chart records and set a compliance action. At this inspection we found that the shortfalls had been met and the compliance action closed. We therefore found that people’s needs were assessed and care but and treatment was planned and delivered in line with an individual care plan.

The last inspection report identified shortfalls under outcome 8 (regulation 12) with unsuitable bins and cleaning schedules. At this inspection we found that the shortfalls had been met and the compliance action closed. We therefore found that people were protected from the risk of infection because appropriate guidance had been followed and people were cared for in a clean, hygienic environment.

The last inspection report recorded shortfalls under outcome 10 (regulation 15) with the environment and set a compliance action. At this inspection we reviewed the actions the provider had taken in response to the compliance action and we found that the shortfalls had been addressed and the compliance action was closed. We therefore found that People who used the service, staff and visitors were protected against the risks of unsafe or unsuitable premises.

The last inspection report recorded a shortfall under outcome 12 (regulation 21) and set a compliance action regarding following up gaps in employment. At this inspection we reviewed the actions the provider had taken in response to the compliance action and we found that the shortfall had been addressed and the compliance action was closed. We therefore found people were cared for, or supported by, suitably qualified, skilled and experienced staff.

The last inspection report recorded a shortfall under outcome 16 (regulation 10) and set a compliance action monitoring or improvements required. At this inspection we reviewed the actions the provider had taken in response to the compliance action and we found that the shortfall had been addressed and the compliance action was closed. We therefore found the provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who use the service and others.

We spoke with two people who used the service and five relatives of people who used the service. They told us “The staff are friendly and caring”, “the staff are always available to discuss any issues”, “I am happy with the care provided” and “I find the home very good”.

We found some areas of concern in relation to the care, welfare and safety of people who used the service such as the potential risks to people who may access the stairs independently.

At this inspection we observed that there were enough staff on duty. This was also confirmed by staff, relatives of people who used the service and by our SOFI observations.

We found that the service had a system in place which confirmed that people’s concerns or complaints were being addressed and acted upon. The provider had implemented a range of audits to monitor the quality and safety of the service but these systems had not always effectively identified some of the concerns we found at this inspection.

We found some areas of potential safety risks to people who lived in the home and we found that people did not always live in a hygienic and clean environment.

We spoke with three people who used the service and two relatives of people who used the service. A relative of a person who used the service said that they were kept informed of any changes in their relative’s care. They also told us that they were happy with the care provided. A person who used the service said, “The staff are always kind and helpful”. Three people who used the service told us that the liked the meals provided at the home.

The provider had distributed feedback questionnaires to relatives of people who used the service in 2012. We looked at the outcome of this survey. This survey had been completed by the relatives of six people who used the service. This showed that most people were happy with the level of care provided at the service.

Many of the people who used the service were unable to tell us their views. We used SOFI to help us understand the experience of people who could not talk with us. We observed that staff spoke with people in a respectful and friendly manner. We observed that staff were available to support people with their meals. For people who required feeding staff supported people to eat at their own pace and they were not rushed.

When we arrived at the home we observed that some people were in the sitting room and they were not being supervised while staff were busy supporting people with their personal care. We also saw that some people had to wait for staff to escort them from their bedrooms to the sitting room.

During this visit some people using the service, their representatives and visitors told us that they were happy with the care provided. Two people told us that the staff are caring and that they get the right support when they need assistance.

Two people told us that they enjoyed their meals, which are good. Positive feedback was received about the new activities organiser who was providing some one to one time with people using the service.

People and their representatives told us that the staff are polite and respectful. People’s representatives told us that the manager was approachable. One person’s representative said that they were happy with the care provided and that the staff interact with people using the service well.

Three people’s representatives told us that that they were not aware of their relative’s care plan and some people’s representatives were not informed of changes.

A person’s representative told us that people are provided with good meals and that they are appropriately supported. Some people told us that the meals are sometimes cold.

Some concern was raised about the security of the home particularly the front door. Supervision of people particularly in the evening could be better.