OSJCT Coombe End Court

Updated 14 June 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

This was a targeted inspection to check whether the provider had met the requirements of the Warning Notice in relation to Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 on a concern we had about security of external doors and monitoring records for risk management plans.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was carried out by two inspectors.

Service and service type

OSJCT Coombe End Court is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. OSJCT Coombe End Court is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced. The first day of inspection was started at 20.00hrs.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with the registered manager, peripatetic operations manager, regional operations manager and five members of staff. We did not spend time observing or speaking with people as this inspection was carried out late in the evening and early morning.

We reviewed seven people’s care records, night care security forms, falls monitoring data and incident forms.

After the inspection

We continued to validate evidence found. We reviewed information for one person’s falls history, a service improvement plan, policies and procedures.

Updated 14 June 2022

About the service

OSJCT Coombe End Court provides care and accommodation for up to 60 people, some of whom live with dementia. Accommodation is provided on two floors accessed by stairs and a lift. People have their own rooms with en-suite facilities and access to communal areas. A garden is accessed from the ground floor. At the time of the inspection there were 50 people living at the service.

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

Systems in place to monitor risks to people were not robust and staff were not recording their actions contemporaneously. Night care security arrangements had been increased to hourly, but we observed shortfalls to these arrangements which placed people at risk of harm. The provider told us they were carrying out a night care whole service review at all of their homes in the organisation. The findings would be shared across the organisations so lessons could be learned, and more effective arrangements put into place.

On our first day of inspection we observed there were areas of the home that required maintenance and needed a clean. Cleaning records had not been completed in one area of the home for four days. We observed some bins were broken and in one toilet not available. On our second day of inspection these shortfalls had been addressed and a different cleaning system had been put in place for kitchen areas.

During our inspection we received a whistleblowing concern about low staffing numbers. We reviewed staffing and found some evidence to substantiate that concern. People and staff told us there were not enough staff at all times. Agency staff were being used but at times there were none available which placed permanent staff under strain. Whilst care was being delivered, it took longer than usual. The provider was actively recruiting and trying to attract new staff to the home.

People had their medicines as prescribed and there were safe management systems in place. Staff had been trained to administer medicines and were observed to be following safe practice. We observed healthcare professionals visiting during our inspection and were told they visited people regularly where needed.

People and staff were testing for COVID-19 following the government guidance. Any visitors to the home had to complete a Lateral flow test prior to entry. All professional visitors had to demonstrate they had been vaccinated for COVID-19 and all staff had also been vaccinated.

Visiting was being supported both indoors and outdoors. Relatives spoke to us about being essential care givers which meant they could visit at any time even during outbreaks of COVID-19. Visitors had to wear personal protective equipment (PPE) which was supplied by the home. We observed staff were wearing the appropriate PPE at all times during our inspection.

Staff had been trained on working safely during COVID-19 and told us they had plenty of PPE available throughout the pandemic. Staff told us they felt supported and had systems in place to support their well-being.

There was a registered manager in post. Feedback about them from relatives and staff was positive and appreciative of their management approach. The registered manager told us they had good support from the provider and their peers.

Quality monitoring was in place and a full range of audits were being completed for all areas. Whilst the monitoring was being carried out it had not identified all of the shortfalls we found during the inspection.

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

Rating at last inspection

The last rating for this service was good (published 17 February 2020).

Why we inspected

The inspection was prompted in part by notification about a person using the service who had died. This inspection did not examine the circumstances of the incident as this was still being investigated by the provider and other agencies. This inspection reviewed the wider safety arrangements for people at night.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively. This included checking the provider was meeting COVID-19 vaccination 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.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified one breach in relation to management oversight and governance at this 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

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.