Archived: Coombe Hill Manor

Updated 19 December 2020

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.

As part of CQC’s response to the coronavirus pandemic we are conducting a thematic review of infection control and prevention measures in care homes. The service was selected to take part in this thematic review which is seeking to identify examples of good practice in infection prevention and control.]

This inspection took place on 29 October 2020 and was announced.

Updated 19 December 2020

Coombe Hill Manor is a care home providing nursing, personal care and support for up to 104 older people. The service has a specialist dementia care unit known as ‘Auguste’ which can accommodate and care for up to 24 people. At the time of our inspection 89 people were living at the home.

The service had a registered manager in post. 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 a legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

This inspection visit took place on 14 and 27 November 2018. Our first visit was unannounced. At our last inspection in 2016 we rated the service Good, with an Outstanding rating in the ‘responsive’ key question. At this inspection we found evidence to support an improved overall rating of Outstanding.

People using the service and their relatives were very positive about the care and support provided at Coombe Hill Manor.

People were kept safe. There were enough staff deployed to ensure people’s needs were being met. Staff had received training around safeguarding vulnerable people and knew what action to take if they had or received a concern.

People received their medicines as prescribed. Any risks associated with people’s care were managed well and people were supported to maintain their independence wherever possible.

People and their relatives told us that they received an effective service. People received the support they required to meet their health and nutritional needs.

Staff spoke positively about the support and training they received. Staff members were safely recruited and received an induction to the home. Staff we spoke with were confident that they provided a high quality service to people and said they would recommend the home to others.

We found people were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

The service was exceptionally caring. The registered manager and her staff team were committed to providing high quality compassionate care. We observed excellent relationships between staff and people using the service. Respect and dignity for people was at the heart of the service with people and their relatives consistently saying that staff were very respectful, kind and caring. There was also a strong emphasis on ensuring compassion, dignity and respect at the end of a person’s life.

The service continued to be exceptionally responsive to people’s changing needs. People were supported to live their life to the full and had access to a wide range of activities, events and facilities. Staff worked creatively to enhance people’s enjoyment of life, including tailoring activities to people’s needs and creating opportunities for people to still be involved in their local community.

Care and nursing staff and the registered manager made sure people’s changing needs were met and strove to ensure people received exceptional person-centred care. People and their relatives concerns and views were listened to and acted upon. Relatives told us the management team was always responsive and approachable.

Individual care and support needs were fully assessed, documented and reviewed at regular intervals. An electronic system for care planning provided a very effective tool for staff to do this.

Good leadership, management and governance of the service supported the delivery of high-quality and person-centred care. The registered manager and provider organisation had effective systems to monitor and improve the quality of service people received at Coombe Hill Manor.

The registered manager kept up to date with good practice and had a clear vision of how they wanted the service to develop and improve.