About the service: 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.