Archived: Combe House

Combe House is a care home which provides personal care and accommodation to people with a learning disability, epilepsy or Autism. At the time of our inspection, six gentlemen were living at Combe House.

The service applied the principles and values of Registering the Right Support and other best practice guidance. These ensure that people who use the service can live as full a life as possible and achieve the best possible outcomes that include control, choice and independence.

People’s experience of using this service and what we found

We found improvements at the service since our last inspection. The new registered manager had created a positive atmosphere within the service and was continuing to drive improvement. However, relatives gave us mixed feedback on the service. This was mostly in relation to staffing levels and how well staff knew people.

Risk assessments in relation to keeping people safe were robust and support plans detailed. This all helped to ensure people received appropriate care by staff.

People told us they felt safe living at Combe House and that staff helped them if they needed it. People said staff assisted them with their medicines and they could speak to staff if they were worried or concerned about anything. Where people had an incident or accident these were responded to and action taken to prevent further accidents.

Changes had been made to the service during the pandemic to help reduce any spread of infection. We had no concerns about the infection prevention and control practices of staff.

The registered manager had an open-door policy and staff told us they felt supported and valued by them. They said they could approach the registered manager and they felt listened to.

A range of audits were completed to ensure people received a good level of care. People and staff were asked for their input into the running of the service and the registered manager worked with external agencies to respond to people’s needs. Relatives said communication between the service and them had started to improve.

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

Rating at last inspection (and update)

The last rating for this service was Requires Improvement (report published 10 December 2019).

At this inspection we found improvements had been made to the service in response to the shortfalls found. As such, the ratings in the Safe and Well-Led key questions have been changed. However, further work was needed to help ensure people were receiving the level of care they deserved.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 8 October 2019. At that inspection we awarded the service a Requires Improvement rating as we found repeated shortfalls from our previous inspection and we felt people may not be receiving safe care.

The service was placed in Special Measures following our inspection. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

At this inspection we reviewed the key questions of Safe and Well-led only and this report covers our findings in relation to these key questions.

The ratings from the previous comprehensive inspection for key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has remained Requires Improvement.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Combe House on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme when we will carry out a fully comprehensive inspection looking at all key questions. If we receive any concerning information we may inspect sooner.

Combe House is a residential care home that provides support and personal care for up to seven adults with learning disabilities. The people who live at Combe House have significant support needs because of their disabilities, communication impairments, mental health and autism.

Although the service was developed and designed according to the values that underpin the Registering the Right Support (Registering the Right Support CQC policy) and other best practice guidance, the provider did

not always ensure that care and support to people was being provided in line with these values which include choice, promotion of independence and inclusion. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence. People using the service should receive planned and co-ordinated person-centred support that is appropriate and inclusive for them.

People’s experience of using this service and what we found:

Most people living at Combe House were not able to tell us verbally about the care they received. We spoke with two people who lived at the service who were able to tell us some information about their care. These two people both said they were happy living at Combe House.

Relatives still had concerns over some risk management, responses to complaints and communication around people’s ongoing care needs and support.

We found there were gaps regarding some areas of risk management. We found there were still shortfalls with specific needs training that staff had not completed. Some staff told us they had not attended training around needs for which they were supporting people with and this was evident when we spoke to staff about their knowledge in areas such as autism and mental health. We found a concern with the way one person’s medicines had been managed which had resulted in them not receiving their medication for six days.

Concerns had previously been raised by relatives around the amount of person-centred activities for people living at the service. We found on inspection there was a lack of meaningful activities for people to do. Management also agreed this was an area they were looking to focus on a improve for people. The lack of person-centred activities had been raised during the last inspection and although the provider had included this in their action plan stating improvements had been made. We did not find any improvements had been made in terms of making activities more meaningful and person-centred for people.

Some people were unable to give their consent or make decisions about their care and supervision. The service was not acting within the requirements of the Mental Capacity Act 2005 by demonstrating how and why decisions were made in a person’s best interest.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

There was a lack of detail around quality monitoring and leadership at the home. Although some service audits had been completed, these were not robust and had failed to identify the issues we found on inspection. Some relatives raised concerns about their overall trust in the service with two relatives telling us they had lost faith and trust in the management of the service. We found some of the information provided on the day of inspection to be conflicting. On one occasion the registered manager admitted to covering for staff for a medicine related issue without investigating what had happened.

Recording of incidents and accidents was not always clear and easy to understand. We did not see any details on how this information is analysed or used to prevent risk of further incidents from taking place. One incident that had been recorded and notified to the local authority had not been notified to the CQC in line with legal requirements.

Improvements had been made to people’s living environment and infection control. People lived in an environment that was clean and suitable for their needs.

Improvements had been made for some people around positive behaviour support. Management at the home had sought support from a professional behaviour specialist to work alongside people in the home and develop plans to support them considering their changing needs. We found this had been recently introduced and so would require more time to embed and develop.

Improvements had been made with staff training since the last inspection around epilepsy rescue medication and fire marshal training. The provider had also considered the issues found in the last inspection with staff deployment. The provider now had adequate levels of staffing on both day and night shifts.

We observed caring interactions between staff and people and we noticed that people were comfortable and smiling when interacting with staff. This created a friendly atmosphere within the home.

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

Rating at last inspection (and update):

The last rating for this service was requires improvement (published 29 May 2019) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

We found that some improvements had been made following the previous inspection. However, in some areas not enough improvement had been made and the provider was still in breach of regulations.

The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections.

Why we inspected:

This was a planned inspection based on the previous rating.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Combe House on our website at www.cqc.org.uk.

Enforcement:

We have identified five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to safe care and treatment, person-centred care, need for consent, complaints and good governance. One breach of the Care Quality Commission (Registration) Regulations 2009.

The breaches in safe care and treatment, person-centred care, need for consent and good governance were continued breaches from the previous inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up:

The overall rating for this service is ‘Requires improvement’. However, we are placing the service in 'special measures'. We do this when services have been rated as 'Inadequate' in any Key Question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services in special measures. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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.

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Combe House is a residential care home that provides support and personal care for up to seven adults with learning disabilities. The people who live at Combe House have significant support needs because of their disabilities, communication impairments, mental health and autism.

People’s experience of using this service:

Most people living at Combe House were not able to tell us verbally about the care they received. Most people had complex needs and some needed one to one support. We observed that people were cared for in a kind way by the staff and they were kept occupied during the day. Some people had the opportunity to go out to the park and for lunch together.

However, relatives expressed concern about the management of people’s care, their lack of involvement and communication with the home. Some concerns were about the limited range of individual activities and stimulation for people. At the inspection we found evidence that the service needed to improve in several areas.

There had been some incidents where there had not been sufficient guidance in place to manage risk due to people’s anxiety and behaviour. We saw this had begun to be addressed by the time of inspection, but these strategies and support had yet to be fully embedded with staff.

The staff team was small, and some worked long hours consistently during the week. It was not clear how staffing levels and deployment was assessed, based on people's needs and individual requirements. There were gaps in staff training which needed to be urgently addressed. We also had concerns about the safety of staffing levels at night and the ability of the service to deal with an emergency.

People’s living environment was not as clean as it should have been, and some parts of the home needed to be better maintained and improved.

Some people were unable to give their consent or make decisions about their care and supervision. At the inspection, the service was not acting within the requirements of the Mental Capacity Act 2005 by demonstrating how and why decisions were made in a person’s best interests.

We considered whether the service was meeting the standards that underpin Registering the Right Support, national best practice guidance for people living with a learning disability. These values include choice, promotion of independence and inclusion for people. There were incidences where the language and treatment used was not always respectful of people as adults which is not in line with the values and standards for people with learning disabilities.

There was a lack of management presence and oversight which we judged had an impact on the overall quality of care. We were unable to find up to date information, such as on complaints and staff training and organisation could be improved. Although some service audits had been undertaken, these were not robust or comprehensive. Concerns we found not been identified. Relatives views were not recorded or acted on. A safeguarding investigation was underway, and the provider had not notified the CQC in line with legal requirements. This was sent in once the inspection had happened.

The registered manager and provider sent us further information after the inspection in response to our feedback. Since the inspection, the provider has agreed to increase management cover and complete more robust checks at the home.

We identified six breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and one breach of the Care Quality Commission (Registration) Regulations 2009. We also made one recommendation about staffing.

Details of action we have asked the provider to take can be found at the end of this report. The provider started to take action immediately following the inspection. They have communicated their intention to improve and to meet with families to address their specific concerns.

Rating at last inspection:

The last inspection report was published in November 2016 and the service was rated as Good.

Why we inspected:

This was an unannounced comprehensive inspection. The inspection was scheduled but we brought it forward due to receiving information of concern. The concerns were about poor management of the service and that some peoples’ needs may not be met due to lack of trained and experienced staff. We received negative feedback from several relatives and we followed up on these concerns at the inspection.

Enforcement:

Action we have told the provider to take is detailed towards the end of this report. Full information about CQC’s regulatory response to the more serious concerns found in inspections and appeals is added to reports after any representations and appeals have been concluded.

Follow up:

We have asked the provider to send us an action plan telling us what they will do to make the improvements needed. We will re-inspect this service in six months to check that the improvements we asked for have been made and that people are receiving safe and supportive care at the standard we expect.

Combe House is a home providing accommodation and personal care for up to seven adults with learning disabilities. It is situated in Horsell, Woking. At the time of our inspection there were no vacancies. The people who lived at Combe House had significant support needs because of their learning disabilities such as physical and communication impairments, autistic spectrum conditions and behaviours considered to be challenging.

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 2008 and associated Regulations about how the service is run.

A family member told us that they felt that people who lived at the home were safe. We saw that people were comfortable and familiar with the staff supporting them.

People who lived at the home were protected from the risk of abuse. Staff members had received training in safeguarding, and were able to demonstrate their understanding of what this meant for the people they were supporting. They were also knowledgeable about their role in ensuring that people were safe and that concerns were reported appropriately.

Medicines were well managed by the home. People’s medicines were managed and given to them appropriately. Records of medicines were well maintained.

We saw that staff at the service supported people in a caring and respectful way, and responded promptly to meet their needs and requests. There were enough staff members on duty to meet the needs of the people using the service.

Staff members received regular relevant training and were knowledgeable about their roles and responsibilities and the needs of the people whom they supported. Appropriate checks took place as part of the recruitment process to ensure that staff members were suitable for the work that they would be undertaking. All staff members received regular supervision from a manager, and those whom we spoke with told us that they felt well supported.

The home was meeting the requirements of The Mental Capacity Act 2005 (MCA). Information about capacity was included in people’s care plans. Applications for Deprivation of Liberty Safeguards (DoLS) authorisations had been made to the relevant local authority to ensure that people who were unable to make decisions were not inappropriately restricted. Staff members had received training in MCA and DoLS, and those we spoke with were able to describe their roles and responsibilities in relation to supporting people who lacked capacity to make decisions.

People’s nutritional needs were well met. Meals provided were varied and met guidance provided in people’s care plans. Alternatives were offered where required, and drinks and snacks were offered to people throughout the day.

Care plans and risk assessments were person centred and provided detailed guidance for staff around meeting people’s needs. Systems for supporting and monitoring people’s needs and behaviours were effectively used and monitored.

A range of activities for people to participate in throughout the week was provided by the home. Staff members supported people to participate in these activities. People’s cultural, religious and relationship needs were supported by the service and detailed information about these was contained in people’s care plans.

The service had a complaints procedure. A family member told us that they knew how to make a complaint but did not have any complaints about the home.

The care documentation that we saw showed that people’s health needs were regularly reviewed. Staff members liaised with health professionals to ensure that people received the support that they needed.

We saw that there were systems in place to review and monitor the quality of the service, and action plans had been put in place and addressed where there were concerns. Policies and procedures were up to date and reflected good practice guidance.

A family member and staff spoke positively about the management of the home. People who lived at the home were familiar with the registered manager and regularly approached him for support.