This inspection took place on 26, 27 and 28 October 2017. It was unannounced and carried out by one inspector.

At the last inspection on 5 and 6 April 2016 we identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider had not ensured people’s medicines were correctly administered. They had not always assessed people’s nutritional risk and had not ensured care plans contained relevant information for staff guidance. The provider had sent us an action plan telling us they would meet these regulations by 31 July 2016. During this inspection we found the actions which the provider told us they would take, to make improvements, had been completed. The provider was meeting the requirements of the regulations.

The Coombs is a care home which can provide care to a maximum of 36 people. At the time of this inspection 34 people lived there. Care was provided in the main house and in three smaller connected units. People in care homes receive accommodation and nursing or personal care as single packages, under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The Coombs provided care to older people, people who lived with dementia and those at the end of their life. There were nurses on duty at all times.

There was an experienced 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.

People were kept safe. Improvements had been made to how people received their medicines and in how their nutritional risks were assessed. Other risks which could potentially impact on people’s health and wellbeing were identified and managed. There were enough staff to meet people’s needs. Staff had been trained and were supported to meet people’s needs safely and appropriately. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The provider’s policies and systems supported this practice and ensured people’s diverse needs were equally met. People’s health needs were responded to and met.

Staff were reported to be kind and compassionate and we observed these qualities in practice. People’s abilities, as well as their disabilities, were understood by staff who adapted their care around this. The care delivered was tailored around people’s individual needs and wishes. People were supported to have quality of life through meaningful activities. Their right to private family life was upheld. There had been improvements in people’s care plans which were personalised and contained relevant information for staff to follow. People’s care was planned with them. People and others were able to raise a concern or complaint and this was taken seriously, investigated and resolved. The staff team reflected on information received in order to learn from this and improve the service.

Improvements to the service were made through effective monitoring and a commitment by the staff team to provide the best service possible to those they looked after. There was strong and supportive leadership in place and staff who felt valued and supported by the senior staff in the care home. People, relatives and staff contributed to the running of the care home and their ideas, suggestions and feedback were valued.

This inspection took place on 5 and 6 April 2016 and was unannounced. The Coombs can provide accommodation and care to up to 40 older people, some who live with dementia. At the time of the inspection there were 30 people living there. The service also provides nursing care with nurses on site at all times.

The service had a registered manager in position. 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.

During this inspection we found three areas of regulation not fully met. These related to the arrangements for: ensuring people had received their medicines as prescribed, identifying and recording people’s nutritional risk and recording what action was taken to address these risks and the maintenance of accurate and relevant care plans. You can see what action we told the provider to take at the back of the full version of the report.

People were at risk of medication errors, for example, not having received their medicines because staff were not accurately maintaining people’s medicine administration records. We found several gaps over a short period of time where staff, after successfully administering a person’s medicine, should have signed to confirm this was the case. Arrangements were not in place to sufficiently monitor these gaps and to find out the reason for the gap.

People received help to eat their food and drink and they were provided with choice. However, the process of assessing people’s levels of nutritional risk and then updating relevant guidance for staff was not always happening and resulting in inaccurate information being recorded. Other risks to people were identified, managed, monitored and recorded, for example, their risk of falls or developing pressure ulcers. Shortfalls in the maintenance of some care plans meant staff and visiting professionals could not always rely on people’s care plans to give them accurate and up to date information on people’s care needs or care delivery. Some care plans however gave detailed information so this indicated that some staff required additional training in this area. Although this had not had a negative impact on people, it did put people at potential risk of not having their nutritional needs and others needs appropriately identified or met. The management team took some action to address this during the inspection and other action, such as further staff training, was to be organised.

People were protected from abuse because staff knew how to report relevant concerns. Robust recruitment practices protected people from those who may not be suitable to care for them. There were enough staff on duty to support people’s needs. This was supported by the regular use of agency staff. These staff usually worked regularly at The Coombs so were well aware of the routine and people’s needs. People had access to health care professionals when they needed this. Care and treatment was given with people’s consent and where people were unable to give consent, they were protected under relevant legislation. People’s decisions and choices were respected and met.

Staff were well trained and supported to provide personalised care and where needed additional training was provided. People were cared for as individuals and their diverse needs were acknowledged and met. People or their representatives were involved in planning and reviewing care and their preferences, likes, dislikes and goals were well identified. Staff knew the people they were looking after well and this made a difference to them. Staff delivered people’s care with extreme kindness and compassion and their dignity and privacy was respected at all times. People received extremely good end of life care from staff who had been s

At this scheduled inspection we also followed up on a compliance action issued on 28 November 2012. During this inspection we particularly spoke with relatives of people who, through frailty or dementia, were unable to speak for themselves.

Staff routinely sought people’s consent before providing care. When a person had limited capacity to consent to care this was recorded and appropriate actions had been taken to protect their rights.

Risk assessments and care plans reflected the care provided to people, these were reviewed and updated regularly. Staff recognised when advice from external professionals was needed and their recommendations were implemented promptly.

Systems were in place to reduce the risk of infection in the home which was a clean and pleasant environment. An audit had recently been completed and improvements had been made in some areas. A relative said, “I do think the cleanliness is really good”.

Actions had been completed to make sure that staff training was up to date and met the needs of people at the home. The staff worked well as a team, reflecting and learning from any incidents. Some staff had lead roles and linked with specialists and local networks to constantly improve standards. One staff member said, “I love my job. I think the staff here are wonderful, they go above and beyond”, another said, “We’re the best”.

Complaints were managed to people’s satisfaction and we saw that specific actions were taken by the manager to prevent a reoccurrence.

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time of this inspection. We have advised the provider of what they need to do to remove the individual's name from our register.

People were offered choices in their everyday lives, including what they ate, when they got up and whether they participated in planned activities. We saw that staff interactions were respectful and at the pace of the person they were working with. Referrals to GPs and other external health professionals were made promptly and their instructions were followed. Recommendations from the Alzheimer’s Society were routinely used within the home.

People told us that they felt safe at OSJCT The Coombs. One person said “Staff are very good. If you ask them for anything they will do it”. Staff worked together to make sure people's needs were met and people were not left waiting for assistance.

We found that although a broad range of training was provided, there were some shortfalls in this area which needed to be addressed. Effective systems were in place to monitor the quality of the service. One person said "You can talk to the managers, they really are kind. I could ask them anything. It’s a lovely home… I would recommend it to anyone”

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 is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008 and to pilot a new inspection process being introduced by CQC which looks at the overall quality of the service.

A registered manager was in place as required by their conditions of registration. 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. The registered manager was present during our inspection.

This service was last inspected on 15 May 2013 when it met all the legal requirements and regulations associated with the Health and Social Care Act 2008.

The Coombs provides accommodation and nursing care for up to 37 people who have nursing or dementia care needs. At the time of our inspection there were 34 people who lived in the home.

The home has 13 bedrooms over 2 floors in the main house and 3 additional 8 bedroom ground floor units attached to the main house.

People were positive about the staff who cared for them. We observed that staff were kind and caring. Staff knew the people who they cared for well. However, although some activities were provided in the home, some people were left unsupervised for long periods or were not provided with daily meaningful activities.  

Staff and the registered manager understood their role and responsibilities of protecting vulnerable people. Risks for individual people had been assessed. Staff were given guidance on how to best support people when they were upset or at risk of harm. People who were able to mobilise independently had the freedom to move around the house and units freely. People could choose where they wanted to eat their meals or relax. For example we saw people eating their meals in different areas of the home.

People and relatives told us they had confidence in the registered manager and the staff. A relative said “The manager is very efficient”. We observed a positive relationship between staff and the registered manager and the senior team. Staff had been trained and recruited in a safe and effective way.

We asked the registered manager about their recent achievements and challenges. We were told “We have introduced a dignity champion in the home and are really working hard at understanding and respecting the importance of dignity of people”. Professionals told us they were happy with the care that was provided by The Coombs. One doctor said “The staff seem very organised, very caring. Clinically very good, they call us appropriately”.