At the last inspection in January 2017 the service was rated Requires Improvement. Following this inspection, the provider agreed to complete regular action plans to show what they were doing to improve the ratings in key questions of Safe, Effective, Responsive and Well Led.

OSJCT Coombe End Court is a “care home”. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

At OSJCT Coombe End Court up to 60 people can be accommodated in one adapted building. There is a unit on the ground floor which supports people living with dementia.

A registered manager was 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.’

Quality Assurance processes were in place. An overarching improvement plan was in place with action plans on how shortfalls were to be met. The registered manager monitored the quality of the service and looked for continuous improvements. Healthcare professionals told us the staff made “great efforts to engage with the local community.”

Care plans were person centred for some people and included their preferences regarding people’s preferred first name and staff were aware of people’s likes and dislikes. “This is me” profiles in bedroom were brief but informative. Life stories were in place for some people. These needed to be further developed particularly for people living with dementia as they helped in developing person centred plans.

Where people used repetitive behaviours to gain staff support we observed an inconsistent approach. Care plans were not developed on how staff were to consistently approach these situations. A professional said for people with misperceived situations some staff need to “validate how people feel” and to be accepting of this. The registered manager said some staff “need reminding, we will do some workshops and refresh the back to basics training.”

There were people who expressed their anxiety and frustrations through verbal and physically aggressive behaviours. Care plans and risk assessments were in place on how to respond to triggers identified. Staff told us they used distraction techniques and where care was refused people were given time to accept support. We observed staff use different techniques to support people when difficult behaviours were presented.

Mental capacity assessments were completed for care and treatment to live at the home. Some capacity assessments did not reflect the DoLS applications. For example a capacity assessment was not completed for people whose medicines were administered by the staff. Also staff had not recorded if the Court appointed deputy was consulted about best interest decisions such as using pressure mats in bedrooms.

People were empowered to make day to day decisions. Staff were knowledgeable about the Mental Capacity Act, people’s varying levels of capacity and had an awareness of Deprivation of Liberty Safeguards (DoLS). Applications to the supervisory body were made for continuous supervision and the least restrictive options were used which meant people were able to move freely around the property.

Although we saw staff were available and spent time with people in Pearl unit, relatives and some professionals raised concerns about staffing levels. All people commented that the staff were very good, but that staff time is task focused. The registered manager told us the staffing levels were appropriate to the dependency needs of people. Staff told us that changes in staffing hours meant people benefitted from consistent staff.

People were supported to access healt

At the comprehensive inspection dated 22 and 23 April 2015 we rated this service inadequate and took enforcement action. We conducted a focus inspection on the 27 January 2016 to check that improvements had been made. This inspection was unannounced. While we found that some improvements were embedded into consistent practice there were insufficient improvements in all areas.

Coombe End Court provides accommodation for up to 60 older people. The accommodation is arranged into three separate units over two floors. The unit on the ground floor supports people living with dementia. The home is run by The Orders of St John Care Trust, a national provider of care.

A registered manager was in post and was recently appointed. 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.

People were at risk from unsafe medicine systems. People were not always having their medicines at their prescribed times. Prescribed medicines were not always in stock which meant doses were missed for some people. Staff signed the medication administration records (MAR) charts but from the stock checks conducted it was clear that some medicines had not been administered. For other people the staff had not signed the MAR charts but had administered the medicines. Protocols were not in place for all medicines prescribed to be taken when required (PRN). This meant staff were not given guidance on when to administer these medicines which included the maximum doses that the PRN’s could be administered.

People living at the service, relatives and staff said there were staff shortages. They said there was heavy reliance on agency staff. The registered manager said recruitment of staff was a priority and that consistent agency staff was used. These agency staff were included in team meetings and handovers to provide consistency. People were sympathetic about staff shortages but wanted the organisation to employ consistent staff to deliver their personal care.

While risk assessments were in place for people with a history of falls and action plans listed the preventative steps to be taken, we found that staff had not reported all falls. We also found the reports of the falls were not clearly documented.

Care plans lacked detail and were not always updated to reflect people’s changing needs. Information was duplicated and at times inconsistent with each other. The people we spoke with were not aware of having a care plan or about review meetings where their needs were discussed.

Quality assurance systems were in place and while shortfalls were identified with the standards of care, actions plans were not always actioned. Internal audits were in place to assess the effectiveness of systems but there were inconsistencies in the areas assessed.

People told us they felt safe with the staff. The people who needed assistance from staff said the staff knew how to use equipment which protected them from harm. Moving and handling risk assessment gave staff guidance on how to assist people with mobility needs. The number of staff and the equipment needed to support the person was included in the risk assessment. Malnutrition Universal Screening Tool (MUST) were used to assess the potential of people to develop malnutrition. Where people were at risk of malnutrition the action plans depended on their weight which included monitoring of food and fluids intake with supplements prescribed and enriched diets served. For people at risk of pressure sores there was equipment used and regular repositioning to relieve pressure points.

People had access to GP and healthcare specialists for their ongoing health needs. People had regular check-ups with optician, dentists and chiropodists and staff or

We carried out an unannounced comprehensive inspection of this service on 22 and 23 April 2015. Breaches of legal requirements were found. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to breaches of Regulation 9 Person centred care, 11 consent, 12 safe care and treatment, 13 restraints and 17 good governance.

We undertook this focused inspection to check they had followed their plan and to confirm they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for OSJCT Coombe End Court on our website at www.cqc.org.uk. We could not improve the rating for 'is the service effective?' from requires improvement because to do so requires consistent good practice over time. We will check this during our next planned comprehensive inspection.

Members of staff knew the actions they must take for people at potential risk of falls, pressure ulcers and from malnutrition. However, members of staff needed to be more aware of the action plans for people who at times needed additional support with moving and handling. For example when to use hoists. Senior staff were knowledgeable about risk management. However, fluid intake intervention records lacked the daily target intake for each person and were not always totalled at the end of the day. This meant the staff were not aware of the people who were not having sufficient fluids and a potential sign of deteriorating health.

People were helped to make day to day decisions and members of staff were knowledgeable about the principles of the Mental Capacity Act 2005 (MCA). People’s capacity to make specific decisions was assessed. However, MCA were not completed for some intimate procedures and we observed the zimmer frame was removed from the side of one person sitting at the table. This meant there was potential for restricting one person’s liberty as the person had to depend on the staff to leave the table.

People said they felt safe and the staff made them feel secure. Members of staff we spoke with had a good understanding of safeguarding of vulnerable adults from abuse and the expectations placed on them to report abuse. They knew that it was their duty to report their suspicions if they witnessed other staff abusing people.

Members of staff said the staffing levels had improved and less agency staff was used. This meant people’s care and treatment was delivered by a consistent staff team.

Training to increase staff skills was provided and they were well supported to deliver people’s care and treatment. Staff said they attended training such as Mental Capacity Act 2005 (MCA), safeguarding adults and other specific training such as dementia awareness.

There was a person centred approach to care planning. People we spoke said they were involved in the planning of their care and their relatives said they were invited to review meetings. Members of staff said the care plans and the quality of the handovers had improved. Care plans detailed the way people liked their care to be provided and the action plans gave staff guidance on meeting people’s current needs.

The quality assurance process was effective. Audits were in place to assess the care and treatment people received. For example, care plans and medicine audits. Accident and incidents were analysed to identify trends and patterns. Where aspects of the service standards were not being met action plans were developed on improving the standards.

People gave us favourable comments about the care provided. One person described the care as “very good.” We observed staff supporting people in a helpful and kindly manner. We saw warm interactions between staff and people.

We found the care provided was variable. Some people had fully up to date care plans and staff knew about significant changes in people’s needs. This was not the case for all people. Some care plans did not include relevant information about how people’s needs were to be met. This included best interest decisions for people living with dementia. Staff also gave us differing information about how they met these people’s needs. Assessment of needs for some people were not accurate or needed to be completed with more information, to ensure appropriate care plans were in place.

People made a range of comments about staffing levels. One person told us there were “enough staff to do the things I need” however another person told us there were “not enough staff.” Staff and managers told us about a recent recruitment drive, which had been effective. They said they anticipated that once all the newly appointed staff were in post, the home would be up to its establishment for staff. The home had not had a registered manager in post for an extended period of time. At the time of our inspection, the provider had a peripatetic manager who was acting into the role.

We spoke with three people in the residential unit and a relative of a person who lived in this unit. One person said “staff and volunteers are very good” another person said “I get on ok with the staff” and the relative said “the staff are good, they know people’s preferred names and the care is good.

Three people in the residential unit said the food was not always of a good standard. The relative told us a “green book” had been introduced for people to record their comments about the food.

We were told the staff knew how to care for them and one person knew they had a care plan in the office but had not read their care plan.

One person told us there were staff shortages and gave us examples of when they had to wait for an unreasonable amount of time for staff support.

The following comments were made by the people in the dementia unit when we asked them about their experiences of living in the home. “They came quickly”, “Everybody seems to be taken care of individually”, “I don’t need to complain,” “It’s alright here” and “It’s lovely”. A member of staff helped one person tell us they did singing for the brain.

We used the Short Observational Framework for Inspectors (SOFI) to observe the interaction staff had with people living with dementia. We observed that although staff used a gentle approach with people and they carried out tasks for people, they did not engage with them. For example, we saw one person direct their conversation to a member of staff but they were not acknowledged and the staff walked away while the person was speaking.

At our last inspection in March 2012, we made three improvement and two compliance actions to ensure service provision was developed. At this visit, we saw significant improvements had been made. The acting manager told us more progress was required in order to ‘get where they wanted to be’. Action plans to address shortfalls were in place and being worked through.

The standard of cleanliness had improved. Additional staff had been recruited and were completing induction programmes. The level of agency staff had reduced. Care planning documentation showed clearer accounts of people’s care needs. People’s dietary intake was monitored. People were supported to minimise their risk of developing a pressure ulcer. There continued however, to be some shortfalls with inconsistent recording of people’s fluid intake.

People told us they liked the staff and were well supported. People could make choices and their rights to privacy and dignity were maintained. People felt safe within the home and staff were aware of their responsibilities to recognise and report a suspicion or allegation of abuse. People told us staff were busy yet they did not feel this impacted upon the care they received. People were well supported with their mobility and nutrition yet there were two occasions when people would have benefitted from more timely staff support. A detailed analysis of the number of falls would have enabled better management of risk and people's safety.

People told us they liked the staff who treated them with respect. We observed staff and saw they took time and encouraged people but did not rush the person to make a choice. One person told us that staff were “absolutely fantastic” and talked about how kind staff were if they needed to use their call bell. Another person told us “the girls are gorgeous”.

Staff told us about the developments in support to them. One care worker told us “we have supervision all the time” and “the seniors are always helping us”.

We observed the home needed to make improvements to prevent the spread of infection and particularly to ensure items in the home can be properly cleansed, odour prevented and people’s own clothing returned to them. Frail people who needed help to take in adequate diets and fluids were not fully supported by the home’s systems. People were not protected against the risk of inappropriate care as information was not documented in their records in an accurate and timely way. Records of training did not evidence that all necessary areas are covered, including training in safeguarding people from risk of abuse.

People said they liked living in the home and they could choose how they spent their daily lives. One person said “I think if you wanted to stay up all night, they wouldn’t pressurise you to go to bed”. People told us there had been many changes recently. One relative said they had noticed a lot of improvements in the standards of care. Another relative told us there were more activities for people to join in with, particularly singing, which their relative enjoyed. Staff told us they had worked hard to address the issues we had found at previous inspections. We saw that some people who had been cared for in bed when we last visited, were now getting up and joining everyone else in the sitting rooms for some periods of time during the day. We observed that one of these people was more alert, they were keen to interact with staff and were clearly putting on weight.

We observed that improvements were needed in the systems for employment and support of staff, to make sure that staff were safe to work with people and were supported in their role. Some care and management records were not completed when they should have been, others did not show full information about people’s needs and others did not show that issues had been followed up when this was needed.

People told us they appreciated the care given to them by the home. One person said “I call them and they’re very good” about staff, and another “I’m quite happy here”. A relative told us that the staff were “all lovely and helpful. It’s a happy home”. We heard a care worker asking a person if they had enjoyed their porridge and the person said “I certainly did”. Staff were available to support people at mealtimes and nutrition has been improved, particularly for frail people.

Some assessments and care plans did not reflect people’s individual needs. Some records care provided needs were not completed accurately. Not all care workers were able to accurately tell us about people’s needs. We observed that some care workers did not follow people’s care plans. Not all beds were made up with clean, dry linen and attention was needed to the cleanliness of some sanitary items.

One person told us that they had no problems with how staff looked after their medicines. This person told us they were able to look after their own inhaled medicine so that they could use it when they needed to. Another person told us that they would like to look after some of their own medicines but understood the reasons why the staff looked after them.

This review considered Outcome 9 and found that the provider was compliant. However, following the review of June 2011, there are some outcome areas which were assessed at that time as being non compliant, so improvements continue to be needed in those areas.

People’s views about the home were mixed. One person told us “I’m looked after” and another “at the moment it’s very nice”. A relative told us “I think it’s very good”. One person described the “smashing food” and another person told us “the girls are very helpful”. A person said “majority of the time the staff are alright, some more so than others, one or two have attitude problems”. A person told us about the activities in the home, saying ”sometimes we play skittles or go down to the centre to have a debate”, however another person told us that there was “nothing to do much”.

We observed that some staff were not assisting people to move in a safe manner. Assessments of need were not always carried out in full and care plans were not accurate or revised when needed. Records showing when people’s needs were met were not always completed and at times were not completed accurately. Some staff we spoke with did not have a full knowledge of people's individual needs. This was of particular concern where people were frail, at risk of falling, at risk of developing pressure ulcers or had nutritional risks. Our observations showed that people were not consistently supported to engage with each other or their surroundings.

We carried out an unannounced inspection of Coombe End Court on the 22 and 23 April 2015. At the last inspection on 18 December 2013, we asked the provider to take action to make improvements in care planning. The provider said they would take action to address the breach of Regulation by 8 January 2014. At this inspection in April 2015 we found there had been some improvements but more were needed.

Coombe End Court provides accommodation to up to 60 older people. There is a unit on the ground floor which supports people living with dementia. The home is run by The Orders of St John Care Trust, a national provider of care.

A registered manager was in post with day to day management responsibility of the home. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

People told us they felt safe living at the home but raised concerns about staffing levels and having to wait for carers to come back after the initial call bell being answered.

Members of staff knew it was their duty to report any poor practice they witness from other staff. However, not all staff were able to show a good understanding of their responsibilities towards safeguarding people from abuse.

Risks to people's safety were assessed but they were not reviewed to ensure the actions taken were appropriate and reduced the potential of reoccurrence. For example, following a fall. People’s needs were assessed and care plans were in place, but these did not always accurately reflect the care and support given or required. These care plans were not person centred as they did not give staff direction on how people liked their care to be delivered.

History has shown that this provider has not been able to maintain a consistent level of improvements and has breached regulations over time at this location.

Audits were in place to assess whether people received the care, appropriate to their needs. For example medicines, care plans and infection control. Incidents and accidents were not appropriately analysed to assess trends and patterns. Staff were not reporting all accidents to the manager. This meant the potential of these accidents reoccurring was not reduced.

Members of staff were not able to show a good understanding of the Mental Capacity Act (MCA) 2005. MCA assessments to establish people’s capacity to make decisions were not undertaken. Staff did not show they were confident on how to gain consent from people who lacked capacity. This meant staff were not informed of the decisions people were able to make or how to support them in making such decisions.

Where people, who lacked capacity, were being deprived of their liberty by locked door with security codes, the service had made appropriate applications to the local authority authorising body. This was to ensure that people were only being deprived of their liberty so that they could get the care and support they needed in the least restrictive way.

DoLS authorised

ation was also gained to provide essential care and treatment to people which included the use of restraint. Care plans showing regard for MCA 2005 were not in place. This meant staff were not given guidance on the restraint to be used which followed the Act and was proportionate and the least restrictive.

On the day of the inspection the staffing levels were consistent with the staffing rota. Staff told us the staffing levels were good and the rotas showed the staffing levels were constant throughout the week. However, we received comments that at the weekend, the staffing levels were lower. The registered manager acknowledged at weekends the number of housekeeping staff on duty was reduced. This meant not all of the staff's roles were covered at weekends.

New staff told us they had to complete an induction programme and had to be assessed on specific tasks before they were able to work unsupervised. Staff told us the training they received was good and refresher training was provided. One to one sessions with staff and their line managers were regular and ensured individual staff had an opportunity to discuss their concerns, professional development and training needs.

People said their meals were good and there was a choice at each mealtime. Staff said the quality of the meals had improved. We observed staff members give explanations to people in a way that people were able to understand. People selected their preferred meal from the choices shown to them by staff. Staff understood the need to promote people’s independence and choice. A member of staff gave an example of how a person had been enabled to improve their ability to walk independently.

Staff told us the manager was approachable, the team worked well together and there was a “caring culture.”

We made recommendations for the service to seek advice and guidance from a reputable source, about end of life care planning, managing difficult behaviours and on how to update emergency plans. This is to build on and develop its provision in these aspects of care.

We found breaches of regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.